Single-incision Anterior Approach Research Articles

Retrospective Study of the Distal Biceps Tendon Repair Using “All-suture” Soft Anchors

Introduction: Distal biceps repair is commonly performed using various fixation devices, each having its advantages and drawbacks. All-suture soft anchor (ASSA) is a recent device mitigating some of the issues associated with previous devices. Materials and Methods: This retrospective study including 20 patients (21 ruptures) aims to evaluate the safety and functionality of ASSA by modified tension-slide technique. All operations were performed through a single-incision anterior approach using two 2.9 mm anchors. All but 1 were men with a mean age of 50.5 years. The mean duration from injury to surgery was 14 days. Results: At a mean follow-up of 11.8 months, compared with contralateral extremity, 18 (86%) of 21 regained full biceps strength with 5/5 flexion-supination power, while 3 displayed 4/5 power. All, except 1, returned to the previous level of function at an average of 24 weeks. As per the modified Mayo Elbow Performance Index, 18 (86%) achieved excellent and 3 (14%) had good results. Complications included lateral antebrachial cutaneous nerve palsy in 12 (resolved in 10), superficial radial nerve palsy in 1 (resolved), and heterotopic ossification in 1. No device-related complications or reruptures were noted. Conclusion: Primary repair of distal biceps tendon ruptures through the use of the ASSA is a viable option, which in conjunction with the proposed modification of tension-slide suture fixation technique yields clinically objective and functional results. Level of Evidence: Level IV—therapeutic.

No functional differences in anatomic reconstruction using a one- versus a two-point fixation for distal biceps tendon rupture through a single-incision anterior approach: A prospective randomized trial.

The distal biceps brachii tendon rupture is a rare injury of the musculoskeletal system. Multiple surgical techniques have been described for distal biceps brachii tendon repairs including suture anchors. The aim of this study was to evaluate the outcome of anatomical distal biceps tendon refixation using either one or two suture anchors for reattachment and to determine whether there are significant clinically important differences on the number of anchors used for refixation. A monocentric, randomized controlled trial was conducted, including 16 male patients with a mean age of 47.4years (range, 31.0 to 58.0) in Group 1 (two suture anchors for refixation) and 15 male patients with a mean age of 47.4 (range, 35.0 to 59.0) in Group 2 (one suture anchor for refixation). All surgeries were performed through an anterior approach. The outcome was assessed using the Oxford Elbow Score (OES), the Mayo Elbow Performance Score (MEPS), the Disabilities of the Arm, Shoulder and Hand (DASH) score, the Andrews Carson Score (ACS) and by isokinetic strength measurement for the elbow flexion after six, twelve, 24 and 48 weeks. Radiographic controls were performed after 24 and 48 weeks. No significant differences between both groups were evident at any point during the follow-up period. A continuous improvement in outcome for both groups could be detected, reaching an OES: 46.3 (39.0 to 48.0) vs. 45.5 (30.0 to 48.0), MEPS: 98.0 (85.0 to 100.0) vs. 99.0 (85.0 to 100.0), DASH: 3.1 (0.0 to 16.7) vs. 2.9 (0.0 to 26.7), ACS: 197.0 (175.0 to 200.0) vs. 197.7.

Distal Biceps Repair With Flexible Instrumentation and Risk of Posterior Interosseous Nerve Injury: A Cadaveric Analysis.

Background:Current repair techniques using cortical button fixation cannot achieve anatomic reconstruction of the distal biceps when performed through a single-incision anterior approach. We recently introduced a single-incision technique that uses flexible guide pins and flexible reamers to allow for an insertion point on the tuberosity that more closely approximates the anatomic footprint of the distal biceps.Purpose:To investigate the safety of this technique with regard to nerve injury by comparing the guide pin position relative to the posterior interosseous nerve in 16 cadaveric elbows through use of a flexible versus rigid reamer.Study Design:Descriptive laboratory study.Methods:A standard single-incision anterior approach was performed in all cadaveric specimens, and the biceps tendon was dissected off the tuberosity. In 8 specimens, a traditional straight guide pin was used with a cortical button repair inserted through the bicipital tuberosity as close to the anatomic tendon footprint as possible. In the remaining 8 specimens, a curved guide was used to insert a flexible guide wire through the tuberosity within the native footprint. Dissection was carried out to measure the distance from the exit point of the guide pin to the posterior interosseous nerve. The 2 groups were compared by use of nonparametric Wilcoxon rank-sum test (significance threshold, P < .05).Results:The mean distance of the guide wire to the posterior interosseous nerve was 11.6 mm (SD, 3.4 mm; range, 6.5-16.9 mm) in the standard rigid instrument group compared with 8.6 mm (SD, 4.2 mm; range, 1.0-13.9 mm) in the flexible instrumentation group; the difference between groups was not statistically different (P = .19; 95% CI, –1.1 to 7.1).Conclusion:Based on our cadaveric testing, the use of flexible instrumentation in a single-incision repair of the distal biceps presents with no significant difference in risk of damage to the posterior interosseous nerve compared with standard rigid instruments. In view of the relatively small number of specimens, however, some caution should be observed when applying these results clinically.Clinical Relevance:As contemporary techniques in sports medicine strive to re-create each patient’s native anatomic characteristics, the use of flexible instruments allows for a more anatomic repair of the distal biceps, and our study demonstrates that it is a safe option. The next step is to evaluate its safety in vivo.

The Intramedullary Cortical Button Technique for Distal Biceps Tendon Repair

The cortical button technique enables the surgeon to restore the distal biceps tendon anatomically to the posterior cortex of the radial tuberosity via single incision anterior approach. Providing high fixation strength it allows immediate postoperative rehabilitation and leads to excellent functional results. The button fixation technique requires a small 1-incision anterior approach without invasive exposure of the proximal radius. Nevertheless, it runs the risk of iatrogenic posterior interosseous nerve (PIN) injury. The blind deployment of the button on the cortical bone at the dorsal aspect of the radial tuberosity places the PIN at risk. The intramedullary cortical button technique represents a further development of the initial cortical button fixation. The button positioning inside the intramedullary canal enables the repair of the distal biceps tendon anatomical without perforating the posterior cortex and consequently not affecting the PIN.

Anatomic Single-Incision Repair of Distal Biceps Tendon Ruptures Using Flexible Reamers

Distal biceps tendon ruptures are treated operatively in active healthy individuals. Treatment consists of either single- or double-incision techniques, each with its own set of advantages and complications. The double incision was traditionally preferred for a more anatomic reattachment of the distal biceps tendon, but there has been renewed interest in the single-incision anterior approach given its lower risk for heterotopic ossification. However, current single-incision techniques cannot achieve anatomic reconstruction of the distal biceps because of a restricted operational angle with standard rigid instruments. The purpose of this study was to introduce a single-incision technique using flexible instrumentation, flexible guide pins, and flexible reamers that allows for an insertion point that better approximates the anatomic footprint of the distal biceps on the tuberosity. This offers the theoretical advantage of restoring forearm supination mechanics, while still maintaining the benefits of a single limited anterior exposure.

Clinical outcomes of single-incision suture anchor repair of distal biceps tendon rupture

Background: Rupture of the distal biceps tendon remains an uncommon injury that is ideally treated by operative repair. Single-incision anterior approach with suture anchor repair is one such method. The purpose of this study was to describe the outcomes in patients who underwent repair of the distal biceps tendon with single anterior incision and suture anchor repair. Methods: One hundred and nineteen patients (120 repairs) with distal biceps tendon repairs between January 1, 2002 and December 31, 2012 were identified and their charts retrospectively reviewed. Twenty-five of these patients participated in additional collection of outcome data including range of motion, strength, pain, satisfaction, and clinical outcome. Results: In the retrospective analysis, the population was 93% male. Average age was 47.3 yr; however, females had a significantly higher mean age (62.5). Most of the patients (69.8%) returned to full or partial work. The additional data collection cohort reported high satisfaction, little-to-no pain on visual analog scale (VAS) and average Disability of the Arm Shoulder and Hand (DASH) scores. Patients with workers’ compensation claims reported significantly higher pain and worse DASH scores. There was small but significant loss of pronation, and a small loss of grip strength that approached significance. Conclusions: Single anterior incision with suture anchor repair may be utilized for repair of ruptures of the distal biceps tendon with good clinical and functional outcomes and minimal loss of range of motion and strength. Females tend to be older at presentation than males with this condition. As in other studies, workers’ compensation claims were associated with poorer clinical outcomes. Level of Evidence: Therapeutic, level IV, case series study.

Factors associated with adverse events after distal biceps tendon repair or reconstruction

Factors associated with adverse events after distal biceps tendon repair or reconstruction are incompletely understood. This study examined factors associated with adverse events, prevalence of adverse events, and rate of second surgeries after distal biceps repair or reconstruction. Between January 2002 and March 2015, 373 adult patients who underwent repair or reconstruction of the distal biceps tendon at 1 of 3 area hospitals were analyzed to determine factors associated with adverse events after surgical repair or reconstruction of the distal biceps tendon. Of 373 distal biceps tendon repairs or reconstructions, 82 (22%) had an adverse event; 5.3% were major adverse events. In multivariable analysis, a single-incision anterior approach and obesity were associated with a higher rate of adverse events. Fifteen patients (18% of patients with an adverse event and 4% of all patients) had a second surgery after distal biceps tendon surgery. Patients should be counseled that 1 in 5 patients will have a minor complication and 1 in 20 patients will have a major complication after surgery on the distal biceps tendon. The most common adverse event is lateral antebrachial cutaneous neurapraxia.

Posterior Interosseous Nerve Incarceration With Endobutton Repair of Distal Biceps

Distal biceps ruptures are uncommon injuries that comprise approximately 3% of all biceps pathology. This injury is most commonly seen in 40- to 60-year-old men, and the mechanism of injury involves a forceful extension movement to a flexed elbow. Without surgical intervention, patients are left with measurable weakness in elbow flexion and supination as well as a cosmetic deformity that often leaves them dissatisfied. Consequently, early surgical repair is advocated for physically active individuals. A variety of surgical approaches and fixation devices are currently used for distal biceps repair. The single-incision cortical button repair for distal biceps avulsions has become popular since Bain introduced the technique in 2000. The advantage of the cortical button biceps repair technique is the significantly higher failure strength than either the 2-incision technique or the suture anchor repair. The initial repair strength of the cortical button technique allows immediate active elbow range of motion and accelerated rehabilitation. Additionally, the single-incision anterior approach is less invasive than the 2-incision biceps repair and results in a lower incidence of heterotopic ossification. One disadvantage of this approach, however, is the risk of injury to the posterior interosseous nerve. The authors report a case in which the posterior interosseous nerve was incarcerated between the cortical button and the radius during acute distal biceps repair, resulting in complete posterior interosseus nerve palsy. This case report details the surgery leading to the nerve palsy and the subsequent nerve exploration that identified the cause of the nerve palsy. Recommendations are made on how to avoid this complication during distal biceps tendon repairs.

Single-Incision Thoracoscopic Right Upper Lobectomy with Chest Wall Resection by Posterior Approach

Lobectomy requiring chest wall resection is usually performed by thoracotomy, but thanks to the advances in the field of thoracoscopic surgery, this procedure can be performed by video-assisted thoracoscopic surgery (VATS). Recent improvements in surgical devices and previous VATS experience have allowed this complex surgery for advanced stages to be undertaken safely. Most of the thoracoscopic lobectomies with rib resection are performed using three to four incisions. We report a different minimally invasive technique for chest wall resection (minimally invasive posterior approach) and VATS right upper lobectomy (single-incision anterior approach).

A single incision surgical new anterior technique for forequarter amputation

Conventionally described standard techniques of forequarter amputation may not be suitable for patients presenting with neglected or maltreated very large tumors of the proximal humerus. Eleven patients with unsalvageable malignant tumors of proximal humerus, who underwent forequarter amputation using a new technique between Jan 2008 to March 2010, were retrospectively analysed. This new single incision anterior approach involves supine positioning of patients, ligation of axillary vessels in the axilla followed by resection of muscles from lateral border and inferior angle of scapula, resection of lateral one-third of clavicle; resection of muscles from vertebral border and superior angle of scapula by applying superolateral traction without any incision over acromioclavicular axis or posterior scapular skin. The average age was 16.27 year and minimum follow-up was 6 months (range 6-24 months). There were seven males and four females. Average duration of surgery was 62 min (range 55-90). Blood loss ranged from 400 to 750 ml. One patient had superficial infection and one patient with metastatic lesion died at 6 months follow-up. This technique is safe, easy, less time consuming, involves small single incision in supine position, has better wound healing and can be used for both small and large tumors of proximal humerus with or without involvement of axillary vessels. Although there was no local recurrence for last 24 months but a long term follow-up is required to comment on its actual rate.

Anterior Approach Total Hip Arthroplasty: The Heuter Interval

The authors report on outcomes from a consecutive series of 450 total hip arthroplasty patients who underwent surgery with a single-incision anterior approach to the hip joint. This approach is relevant to minimally invasive two-incision total hip arthroplasty, since the anterior portion of the two-incision technique is identical to that described here. Complications with the single incision technique, including thigh sensory changes and periprosthetic femur fractures, are reported, and the authors discuss how these may be avoided. In the authors' experience with total hip arthroplasty through the anterior approach, patients report reduced postoperative pain and experience more rapid recovery, with less surgical scarring.

Single-incision Anterior Approach for Total Hip Arthroplasty on an Orthopaedic Table

Dislocation remains the leading early complication of total hip arthroplasty; surgical approach and implant positioning have been recognized as factors influencing total hip arthroplasty stability. We describe a total hip arthroplasty technique done through a single, tissue sparing anterior approach that allows implantation of the femoral and acetabular components without detaching or sectioning any of the muscles and tendons around the hip joint. A series of 437 consecutive, unselected patients who had 494 primary total hip arthroplasty surgeries done through an anterior approach on an orthopaedic table from September 1996 to September 2004 was reviewed. There were 54 hybrid and 442 uncemented hips in the 437 patients (57 bilateral). The average patient age was 64 years. Radiographic analysis showed an average abduction angle of 42 degrees , with 96% in the range of 35 degrees to 50 degrees abduction. The average cup anteversion was 19 degrees with 93% within the target range of 10 degrees to 25 degrees . Postoperative leg length discrepancy averaged 3 +/- 2 mm (range, 0-26 mm). Three patients sustained dislocations for an overall dislocation rate of 0.61%, and no patients required revision surgery for recurrent dislocation. There were 17 operative complications, including one deep infection, three wound infections, one transient femoral nerve palsy, three greater trochanter fracture, two femoral shaft fractures four calcar fractures, and three ankle fractures. Operative time averaged 75 minutes (range 40-150 minutes), and the average blood loss was 350 mL (range, 100-1300 mL). The mean hospital stay was 3 days (range, 1-17 days). The anterior approach on the orthopaedic table is a minimally invasive technique applicable to all primary hip patients. This technique allows accurate and reproducible component positioning and leg-length restoration and does not increase the rate of hip dislocation. Therapeutic study, Level IV-1 (case series). See the Guidelines for Authors for a complete description of levels of evidence.

A minimally invasive single incision anterior approach for total hip arthroplasty: Early results in 49 cases

A modified and limited Smith Petersen approach was used for prosthetic hip replacement. The exposure of the proximal femur required the use of a traction table. We operated on 49 patients: 15 of them underwent cemented bipolar hemiarthroplasty, and 34 had a total hip arthroplasty. Skin incision ranged from 6 to 11 cm (average 7.8 cm). Patients subjective grading was evaluated according to a pain scale (0-10); early functional outcome was rated on postoperative days two, seven and 30 according to a functional scale of active flexion and abduction. Average active flexion on the second postoperative day was 68.4, and active abduction 14.7. Progressive increment of average active flexion and abduction was observed on day 7 (78.7 flexion - 22.3 abduction) and day 30 (88.4 flexion 29.2 abduction). All patients were allowed progressive weight-bearing depending on their postoperative pain. Most of them were fully weight bearing from the first day. This surgical approach, characterized by preservation of the muscular insertions, is associated with reduced postoperative pain and fast functional recovery. (Hip International 2004; 14: 233-8).