In distal biceps tendon ruptures, re-attachment to the radial tuberosity should ensure adequate tendon to bone contact for optimal healing

Charalambous, CP

Funk, L

Gullett, TK

Philips, N

Ravenscroft, MJ

English

PubMed

University of Salford Institutional Repository

TECHNICAL SECTIONAnn R Coll Surg Engl 2009; 91: 161–170 165dressing should also be easy to remove with the least discomfortand distress to the patient and their family. Most dressings arebulky, hard to apply or remove, and may fall off in an activechild.1–3 We describe a dressing using Allevyn (Smith & NephewHealthcare, Healthcare House, Hull, UK).TECHNIQUEThe lower end of dressing is split to form two equal lateral flapswhich will sit on the pubo-scrotal area and secure with adhesiveplaster. The rest of the dressing is rolled into a cylindrical shapewrapping round the penile shaft and is closed on the dorsal aspectusing two interrupted silk stitches. The top end of the dressing is leftopen to allow the urinary catheter to come through (Fig. 1). Removalof the dressing is carried out after either 2 or 5 days depending onthe type of repair. The plaster is sprayed with an alcohol-based dis-infectant and stitches are cut. The dressing, being non-adherent, iseasily separated off from the wound (Fig. 2).DISCUSSIONAllevyn has a unique tri-laminate structure, inner non-adherent,central absorbent and outer water- and microbial-proof layers.None of the 85 dressings after repair (63 Mathieu’s, 11 Duckett’sand 11 Bracka’s) dislodged prematurely. All dressings wereremoved on the ward with minimal distress to the patients. Therewas no early wound infection. This non-adherent and tri-laminatedressing is simple to apply and compatible with early dischargefrom hospital.4References1. Cilento Jr BG, Stock JA, Kaplan GW. Pantaloon spica cast: an effective methodfor postoperative immobilisation after free graft hypospadias repair. J Urol1997; 157: 1882–3.2. Whitaker RH, Dennis MJ. Silastic foam dressing in hypospadias surgery. Ann RColl Surg Engl 1997; 69: 59–60.3. Davalbhakta A, Summerlad BC. Cavi-Care dressing for hypospadias repair. Br JPlast Surg 1999; 52: 325–6.4. Grobbelaar AO, Laing JH, Harrison DH, Sanders R. Hypospadias repair: theinfluence of postoperative care and a patient factor on surgical morbidity. AnnPlast Surg 1996; 37: 612–7.BACKGROUNDIn distal biceps tendon ruptures, re-attachment to the radialtuberosity should ensure adequate tendon to bone contact foroptimal healing.TECHNIQUEUsing a transverse incision at the cubital crease, we dissect to theradial tuberosity into which two suture anchors (5.0 mm FASTINRC, Mitek, UK or 3.5 mm Twinfix, Smith-Nephew, UK) are insert-ed, each with two suture strand pairs. The tendon is held outsidethe wound during suture passing. Each pair of distal anchorsutures (Fig. 1, X1) is passed through the distal part of the ten-don. One strand is passed in a zigzag fashion through the tendon(Fig. 1, C and D) whilst the other (Fig. 1, A and B) is passedstraight posterior to anterior. The four strands of the proximalanchor (Fig. 1, X2) are passed to form two mattress suturesthrough the proximal tendon when tied (Fig. 1, E and F).Tightening is performed in a specific sequence, initially pullingon strands A and B to position tendon to bone, and then tighten-ing these to the corresponding suture strand of their pair. The twosuture pairs are tied to each other. Following this, the mattresssutures of the proximal anchor are tied individually and then overthe tendon to each other, creating a box type pattern. The secondL-Configuration re-attachment of distalbiceps tendon ruptureCP CHARALAMBOUS1, TK GULLETT1, N PHILIPS2, L FUNK3,MJ RAVENSCROFT11Dept Shoulder and Elbow Surgery, Stepping Hill Hospital,Stockport, UK2Dept Upper Limb Surgery, Wythenshawe Hospital, Manchester, UK3Dept of Upper Limb Surgery, Wrightington Hospital, Wigan, UKCORRESPONDENCE TOCP Charalambous, Department of Shoulder and Elbow Surgery,Stepping Hill Hospital, Poplar Grove, Hazel Grove, StockportSK2 7JE, UK. E: bcharalambos@hotmail.comFigure 2 Dressing removal.Figure 1 Application of a non-adherent, tri-laminate (Allevyn) dressing.TECHNICAL SECTIONAnn R Coll Surg Engl 2009; 91: 161–170166anchor sutures are then tightened bringing tendon down onto thebone in an L-configuration (Fig. 2).DISCUSSIONThe technique is simple to perform, provides a sound repair, andensures a large tendon-to-bone surface contact. We have per-formed this in 25 patients with no cases of tendon re-rupture.BACKGROUNDVaricose vein due to superficial venous insufficiency is a commonproblem world-wide1,2 and endovenous laser ablation (EVLA)has been used for treatment for at least 6 years.3 Skin burn andpermanent staining can occur when the laser ablation is used forveins which are in very close proximity to the skin4 particularly inthin, fairer individuals without much subcutaneous fat. While per-forming EVLA in these patients, it may be difficult to push thedistal vein away from the skin with tumescent.TECHNIQUEThe authors describe a new technique, which is a novel combi-nation of EVLA of the proximal superficial vein and stripping oravulsion of the distal vein (Fig. 1). The authors call this technique‘laser avulsion’. Because there is enough fat in the thigh and thelong saphenous vein (LSV) is deep seated, EVLA of the proximalLSV segment can be safely undertaken. In the distal thigh andaround the knee where the vein can be close to the skin, one canmake a small (2 mm) cut down on to the vein, remove the laserfibre but leave the sheath in situ and tie the vein secure to thelaser sheath. The ablated vein is then disconnected proximallyand the sheath is pulled out with the distal segment of the non-ablated vein. Therefore, the proximal thigh segment of the LSV islaser ablated and lower thigh, knee and upper leg segment of thevein is stripped.DISCUSSIONThe advantage of this procedure is one can avoid both the groinincision of the Trendelenburg procedure and potential permanentdiscoloration and skin burn of the lower aspect of superficial veinwhich may happen in EVLA.References1. Campbell B. Varicose veins and their management. BMJ 2006; 333: 287–92.2. London NJ, Nash R. ABC of arterial and venous disease. Varicose veins. BMJ2000; 320: 1391–4.3. Min RJ, Zimmet SE, Isaacs MN, Forrestal MD. Endovenous laser treatment ofthe incompetent greater saphenous vein. J Vasc Intervent Radiol 2001; 12:1167–71.4. Durai R, Srodon PD, Kyriakides C. Endovenous laser ablation for superficialvenous insufficiency. Int J Clin Pract 2008 [Epub ahead of print].Figure 1 Anterior to posterior view of the biceps tendon repair. A, C andB, D refer to the two suture strand pairs from the distal anchor, X1. E andF refer to the two strand pairs from the proximal anchor X2.Figure 2 Lateral view of the biceps tendon showing its L-shaped re-attach-ment to the radial tuberosity using bone anchors.‘Laser avulsion’R DURAI, C KYRIAKIDESDept of Vascular and Endovascular Surgery, Barts and TheLondon NHS Trust, The Royal London Hospital, London, UKCORRESPONDENCE TOC Kyriakides, Consultant Vascular and Endovascular Surgeon, Bartsand The London NHS Trust, The Royal London Hospital, LondonE1 1BB, UK. T: + 44 (0)20 7377020; F: + 44(0)20 7377684;E: constantinos.kyriakides@bartsandthelondon.nhs.ukFigure 1 ‘Laser avulsion’ which is a novel combination of laser ablationof proximal long saphenous vein (LSV) and avulsion of the distal thigh andknee segments of LSV. After laser ablation, the laser fibre is removed andthe vein is tied on to the sheath. The lower shaded segment of vein isavulsed by pulling the sheath.

L-configuration re-attachment of distal biceps tendon rupture

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