Progressive osteolysis of the radius after distal biceps tendon repair with the bioabsorbable screw

Distal Biceps Repair Using an All-Suture Anchor Technique

Distal biceps ruptures are common injuries that lead to significant decrease in elbow supination strength and pain. This Technical Note describes a single-incision distal biceps tendon repair using 2 knotless suture anchors. This technique is easily reproducible, is efficient, and has the unique benefits of decreasing the risk of heterotopic ossification and damage to neurovascular structure while providing similar outcomes to other described fixation techniques.

Dynamic Anterior Stabilization of the Shoulder With Adjustable-Loop Device

Dynamic anterior stabilization of the shoulder is a surgical procedure based on a triple soft-tissue block. This procedure is designed to fit within a gray zone between the Bristow-Latarjet procedure and the Bankart procedure, where the patient would not need a bone graft; however, capsular reconstruction alone may be insufficient to yield reliable stabilization. This article describes dynamic anterior stabilization of the shoulder using the adjustable-loop device.

Bicortical suspensory button fixation yields greater ultimate load to failure over unicortical all-suture anchor fixation in distal biceps brachii tendon repair

BACKGROUND

Various distal biceps tendon repair techniques exist, each with their own biomechanical profile. Recently, all-suture anchor fixation has recently become an intriguing option for distal biceps fixation, compared with the proven track record of the suspensory cortical button. In addition, intramedullary techniques have been utilized as a means to avoid complications such as nerve damage seen with extramedullary fixation.

PURPOSE

The purpose of this study is to perform a comparative biomechanical analysis of 4 unique distal biceps tendon fixation methods: Unicortical/intramedullary all-suture anchor fixation (UIAS), Bicortical/extramedullary all-suture anchor fixation (BEAS), Unicortical/intramedullary suspensory button fixation (UISB), and Bicortical/extramedullary suspensory button fixation (BESB).

STUDY DESIGN

Controlled Laboratory study.

METHODS

24 fresh-frozen cadaveric elbows were randomized into 4 groups providing data from 6 specimens, with each group undergoing a different repair technique. The specimens underwent 2 studies: Cyclic loading and Ultimate Load to failure (ULTF) testing. The repaired elbows were cycled 3000 times between 0 and 90 degrees of flexion, with displacement under cyclic loading at the repair site measured using a differential variable reductance transducer. ULTF test was performed with the elbow flexed at 90 degrees. The modes of failure were recorded.

RESULTS

The mean cyclic displacements between the 4 groups were as follows: UIAS: 1.45 ± 1.04 mm; BEAS: 2.75 ± 1.32 mm; UISB: 1.45 ± .776 mm; BESB: 2.66 ± 1.18 mm (p= 0.077). Bicortical repairs displayed greater displacement after cyclic loading when compared with unicortical repairs regardless of anchor used (p= 0.007). The mean ULTF for each group was as follows: all-suture intramedullary: 200 N; all-suture extramedullary: 330 N; cortical-button intramedullary: 256 N; cortical-button extramedullary: 342 N). All-suture unicortical/intramedullary repair had a significantly lower ULTF (200 N) compared with cortical-button Bicortical/extramedullary repair (342 N) (p=0.043).

CONCLUSION

Bicortical/extramedullary suspensory button fixation demonstrated a greater ultimate load to failure when compared with unicortical/intramedullary all-suture anchor fixation. These findings suggest that bicortical/extramedullary suspensory cortical button fixation is a biomechanically superior construct as compared to unicortical/intramedullary all-suture anchor fixation. However, there was no significant difference in ULTF between extra-medullary, Bicortical button or Bicortical, all-suture anchor fixation.

Biomechanical Comparison of Two Fixation Techniques for Lateral Ulnar Collateral Ligament Repair With Ligament Bracing

PURPOSE

Ligament bracing is a technique of suture reinforcement that can be used to augment lateral ulnar collateral ligament repair in the treatment of posterolateral rotatory instability of the elbow, thereby improving early stability of the repair. However, multiple failures of the ulnar anchor during implantation have been documented. We hypothesized that the use of a cortical button for ulnar fixation of the ligament brace would be biomechanically comparable to a suture anchor construct.

METHODS

Sixteen elbows were tested with a materials testing machine. The intact, dissected, and repaired lateral collateral ligament complex was tested with a cyclic varus rotational torque of 0.5-3.5 Nm in 120°, 90°, 60°, and 30° elbow flexion. For the repair, the specimens were randomized into 2 groups: ulnar fixation of the ligament bracing using a suture anchor and ulnar fixation of the ligament bracing using a cortical button. The number of implant failures was documented. A load-to-failure protocol was conducted in 90° elbow flexion.

RESULTS

Load to failure was comparable and was found to be 20.7 Nm in the suture anchor group and 21.8 Nm in the cortical button group. Laxity after ligament bracing did not differ significantly between suture anchor and cortical button fixation. Compared with the native ligament, the laxity was significantly reduced after ligament bracing. The failure mode was slippage of the suture tape through the humeral anchor in all cases. Additionally, the capitellum was damaged in 9 of 16 cases.

CONCLUSIONS

A cortical button for ulnar fixation of the ligament bracing was comparable with a suture anchor fixation with regard to biomechanical properties such as laxity and load to failure.

CLINICAL RELEVANCE

A cortical button fixation is less prone to failure of insertion. This would improve the implantation technique, while clinical results are expected to be comparable.

Operative vs. nonoperative treatment of distal biceps ruptures: a systematic review and meta-analysis

BACKGROUND AND HYPOTHESIS

Ruptures of the distal biceps tendon are most commonly due to traumatic eccentric loading in the middle-aged male population and can result in functional deficits. Although surgical repair has been demonstrated to result in excellent outcomes, there are few comparative studies that show clear functional benefits over nonoperative management. The aim of this systematic review and meta-analysis is to compare the functional outcomes of operative and nonoperative management for these injuries. We hypothesized that operative treatment would be associated with significantly superior outcomes.

METHODS

According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic review of the literature was performed using MEDLINE, SPORTDiscus, CINAHL (Cumulative Index to Nursing and Allied Health Literature), CENTRAL (Cochrane Central Registry of Controlled Trials), Embase, and Web of Science databases. Outcomes of interest included range of motion (ROM), strength, endurance, and patient-reported outcomes including Disabilities of the Arm, Shoulder and Hand (DASH), Mayo Elbow Performance Score (MEPS), and visual analog scale (VAS) for pain scores. Summary effect estimates of the mean difference between operative and nonoperative management for each outcome were estimated in mixed effects models.

RESULTS

Of an initially identified 6478 studies, 62 reported outcomes for a total of 2481 cases (2402 operative, 79 nonoperative), with an overall average age of 47.4 years (47.3 for operative, 50.3 for nonoperative). There were 2273 (98.5%) males and 35 (1.5%) females among operative cases, whereas all 79 (100%) nonoperative cases were males. Operative management was associated with a significantly higher flexion strength (mean difference, 25.67%; P < .0001), supination strength (mean difference, 27.56%; P < .0001), flexion endurance (mean difference, 11.12%; P = .0268), and supination endurance (mean difference, 33.86%; P < .0001). Patient-reported DASH and MEPS were also significantly superior in patients who underwent surgical repair, with mean differences of -7.81 (P < .0001) and 7.41 (P = .0224), respectively. Comparative analyses for ROM and pain VAS were not performed because of limited reporting in the literature for nonoperative management.

CONCLUSION

This study represents the first systematic review and meta-analysis to compare functional and clinical outcomes following operative and nonoperative treatment of distal biceps tendon ruptures. Operative treatment resulted in superior elbow and forearm strength and endurance, as well as superior DASH and MEPS.

Histopathological and Radiographic Features of Osteolysis After Fixation of Osteochondral Fragments Using Poly-L-Lactic Acid Pins for Osteochondral Lesions of the Talus

BACKGROUND

Fixation of osteochondral fragments is a potential option for treating an osteochondral lesion of the talus (OLT) involving large lesions in the remaining articular cartilage surface. Bioabsorbable devices, especially those made of poly-L-lactic acid (PLLA), can be used for the fixation of an OLT. Postoperative osteolysis surrounding the PLLA pins is occasionally observed; however, the significance of osteolysis remains unknown.

PURPOSE

To elucidate the association between osteolysis surrounding the PLLA pins, histopathological findings in subchondral bone, and preoperative Hounsfield unit (HU) values at the pin fixation site.

STUDY DESIGN

Case Series; Level of evidence, 4.

METHODS

This retrospective analysis included 20 patients with OLT (11 men and 9 women; mean age, 20.9 years; 1 bilateral case). Tissue from the osteochondral fragment was collected intraoperatively using a bone biopsy needle for histological evaluation. The fragment was fixed through the biopsy hole using a PLLA pin. Osteolysis surrounding the PLLA pin was assessed at 1 year postoperatively using magnetic resonance imaging (MRI). Histopathological scores were assigned based on trabecular bone loss, empty lacunae, inflammatory granulation tissue, cartilage-like tissue, and the presence of osteoclasts. The HU values around the pin insertion site, detected on the postoperative MRI scans, were measured using the region of interest based on the preoperative coronal and sagittal computed tomography (CT) images.

RESULTS

Osteolysis was observed postoperatively in 9 ankles (42.9%). Histopathological evaluation revealed that the osteolysis group had a significantly higher pathological score than the nonosteolysis group (10.2 vs 6.3; P < .001). Lower HU values were identified in the osteolysis group on preoperative coronal and sagittal CT images (P < .05). The histopathological score negatively correlated with preoperative HU values (Pearson r = -0.46; P = .037).

CONCLUSION

Intraoperative biopsy of the OLT allowed for histopathological evaluation of the same site as that of the PLLA pin fixation. Our findings suggest that preoperative subchondral trabecular deterioration is associated with the incidence of postoperative osteolysis surrounding the PLLA pin. Additionally, low preoperative HU values in subchondral bone under OLT may serve as a predictor of osteolysis surrounding the PLLA pin.

Interference Screw Versus Suture Anchors for Femoral Fixation in Medial Patellofemoral Ligament Reconstruction: A Biomechanical Study

Background:

Femoral-sided graft fixation in medial patellofemoral ligament (MPFL) reconstruction is commonly performed using an interference screw (IS). However, the IS method is associated with several clinical disadvantages that may be ameliorated by the use of suture anchors (SAs) for femoral fixation.

Purpose:

To compare the load to failure and stiffness of SAs versus an IS for the femoral fixation of a semitendinosus autograft in MPFL reconstruction.

Study Design:

Controlled laboratory study.

Methods:

Based on a priori power analysis, a total of 6 matched pairs of cadaveric knees were included. Specimens in each pair were randomly assigned to receive either SA or IS fixation. After an appropriate reconstruction procedure, the looped end of the MPFL graft was pulled laterally at a rate of 6 mm/s until construct failure. The best-fit slope of the load-displacement curve was then used to calculate the stiffness (N/mm) in a post hoc fashion. A paired t test was used to compare the mean load to failure and the mean stiffness between groups.

Results:

No significant difference in load to failure was observed between the IS and the SA fixation groups (294.0 ± 61.1 vs 250.0 ± 55.9; P = .352), although the mean stiffness was significantly higher in IS specimens (34.5 ± 9.6 vs 14.7 ± 1.2; P = .004). All IS reconstructions failed by graft pullout from the femoral tunnel, whereas 5 of the 6 SA reconstructions failed by anchor pullout.

Conclusion:

In this biomechanical study using a cadaveric model of MPFL reconstruction, SA femoral fixation was not significantly different from IS fixation in terms of load to failure. The mean load-to-failure values for both reconstruction techniques were greater than the literature-reported values for the native MPFL.

Clinical Relevance:

These results suggest that SAs are a biomechanically viable alternative for femoral-sided graft fixation in MPFL reconstruction.

Complications After Distal Biceps Tendon Repair: A Systematic Review

BACKGROUND

Distal biceps tendon injuries typically occur in the dominant arm of men in their fourth decade of life. Surgical repair restores flexion and supination strength, resulting in good functional outcome. The complication profile of each surgical approach and fixation technique has not been widely studied in the literature.

PURPOSE

To report the rate of complications after repair of complete distal biceps ruptures, to classify them according to surgical approach and fixation technique, and to analyze risk factors and outcomes of the individual complications.

STUDY DESIGN

Systematic review.

METHODS

Studies published in English on primary repair of the distal biceps between January 1998 and January 2019 were identified. Data on complications were extracted and classified as major and minor for analysis. A quantitative synthesis of data was done to compare the complication rates between (1) limited anterior incision, extensile anterior incision, and double incision and (2) 4 fixation methods.

RESULTS

Seventy-two articles including 3091 primary distal biceps repairs were identified. The overall complication rate was 25% (n = 774). The major complication rate was 4.6% (n = 144) and included a 1.6% (n = 51) rate of posterior interosseous nerve injury; 0.3% (n = 10), median nerve injury; 1.4% (n = 43), rerupture; and a 0.1% (n = 4), synostosis. Brachial artery injury, ulnar nerve injury, compartment syndrome, proximal radius fracture, and chronic regional pain syndrome occurred at a rate of <0.1% each. The majority of nerve injuries resolved with an expectant approach. The minor complication rate was 20.4% (n = 630). The most common complication was lateral cutaneous nerve injury (9.2%, n = 283). An extensile single incision was associated with a higher rate of superficial radial nerve injury when compared to limited single incision(6% vs 2.1%, P = .002). Limited anterior single incision technique had a higher rate of lateral antebrachial cutaneous nerve injury compared to extensile single incision. (9.7% vs 5.2%, P = .03). Synostosis occurred only with double incision. Fixation technique had no significant effect on rerupture rate and posterior interosseous nerve injury rate.

CONCLUSION

This is the largest analysis of complications after distal biceps repair, indicating a major complication rate of 4.6%. This study provides valuable data with regard to the choice of technique, surgical approach, and rate of complications, which is essential for surgical planning and patient consent.

REGISTRATION

CRD42017074066 (PROSPERO).

Acute distal biceps tendon ruptures: anatomy, pathology and management - state of the art

All patients with acute complete distal biceps tendon ruptures who are not low demand or medically unfit to proceed with surgery are offered operative repair. This restores arm shape, supination strength and function, and decreases their cramping symptoms. Surgical repair technique varies significantly depending on location and training centre. Nuances in technique and appropriate implant selection need to be noted in order to achieve a strong repair allowing early active range of motion. Intimate knowledge of distal biceps tendon anatomy is key to avoid complications associated with the different approaches. The cumulative body of evidence on complications, coupled with knowledge of the different biomechanical construct strengths of the alternative methods of fixation, points to the use of the cortical button technique without the addition of an interference screw. Subtle variations in drill hole positioning on the bicipital tuberosity secures either an anatomic or non-anatomic repair. Anatomic repair results in greater supination peak torque and fatigue strength, and in greater flexion fatigue strength. It is advisable to perform an anatomic repair in elite athletes or those patients who significantly rely on supination strength and endurance for their livelihood. A universal postoperative protocol is suggested for all repairs.

Clinical and sonographic evaluation of Endobutton distal biceps brachii tendon repair: what constitutes normal post-operative appearances?

OBJECTIVE

Distal biceps brachii tendon (DBBT) rupture is an uncommon but functionally significant injury given the loss of supination, flexion strength and pain that often result. Prompt surgical repair is preferred in most patients. Clinicoradiological post-operative follow-up is typically performed to assess DBBT repair integrity and function, frequently using ultrasound, though to date, no studies have described post-operative DBBT repair sonographic appearances. The purpose of this study was to evaluate post-operative DBBT sonographic appearances in the context of Endobutton repair with the following aims:i.Establish typical ultrasound appearances 12 months post-surgeryii.Establish the relationship between ultrasound appearances and clinical/functional outcomes.

MATERIALS AND METHODS

Sixty patients between February 2016 and October 2017 undergoing DBBT repair were prospectively recruited, all undergoing clinical and sonographic assessment 12 months post-surgery. Ultrasound data was collected on tendon integrity, tendon calibre and presence of intratendinous calcification, peritendinous fluid and peritendinous soft tissue/scarring. Clinical data was collected on active range of motion (ROM) (flexion, extension, supination, pronation) and strength (flexion and supination).

RESULTS

A total of 57/60 patients had intact DBBT repairs identified sonographically and clinically at 12 months. DBBT repairs had significantly increased cross-sectional area (mean 260%, 95% CI: 217%, 303%) compared with non-operated DBBT. Ninety-three percent of DBBT repairs were hypoechoic. Thirty percent contained intratendinous calcification. Peritendinous fluid/soft tissue was rarely observed. There was no significant correlation between DBBT calibre and strength/ROM parameters.

CONCLUSION

Normal post-operative sonographic appearances of Endobutton DBBT repair comprise a hypoechoic tendon significantly increased in calibre compared with non-operated tendon ± intratendinous calcification. DBBT repair calibre varies greatly, but is not associated with any significant difference in strength/ROM.

Reinsertion of distal biceps ruptures with a single anterior approach: analysis of 14 cases using tension-slide technique and interference screw

Background:

Several techniques of surgical repair of biceps tendon ruptures are described in literature. Cortical button repair have shown minimal loss of elbow flexion, supination and strength. In this retrospective study we report the outcomes in terms of elbow function and complications of tension-slide technique and interference screw.

Matherials and methods:

14 patients with complete distal biceps tendon rupture were included in the retrospective study and treated with the same tension-slide technique (BicepsButton® - Arthrex, Inc, Naples, Florida) evaluating the clinical and functional outcomes and the complication rate with a follow-up average of 18 months.

Results:

The flexion recovered compare to the healthy contralateral was 96% (min 115° - max 135°; average 128°), the extension was 97% (min: -2° - max 15°; average 4°), the supination was 90% (min 20° - max 90°; average 75°), the pronation was 95% (min 15° - max 90°; average 76°). The mean Disabilities of Arm, Shoulder and Hand (DASH) score was 8.1 ± 10.5 and Mayo Elbow Performance Score overall (MEPS) score was 97.6 ± 8.2. Two patients had LABCN paresthesia, one case, treated 2 months after injury, had posterior interosseus nerve palsy. One patient had heterotopic ossification at the radiological examination without consequences for the clinical performances. No case of non-traumatic tendon re-rupture and no case of ROM deficiency > 20%. In all case the cortical button remains well positioned and no case of osteolysis were reported.

Conclusions:

Distal biceps tendon repair with BicepsButton® system seems to be a safe, relyable and reproducible technique providing excellent clinical, functional and radiological outcomes. Comparing with other techniques the BicepsButton® system has the advantages of the single approach procedures, the reduction of surgical time and risk of heterotopic ossifications. (www.actabiomedica.it)

Biomechanical Comparison of Onlay Distal Biceps Tendon Repair: All-Suture Anchors Versus Titanium Suture Anchors

BACKGROUND

A rupture of the distal biceps tendon is the most common tendon rupture of the elbow and has received increased attention in the past few years. Newly developed all-suture anchors have the potential to minimize surgical trauma and the risk of adverse events because of the use of flexible drills and smaller drill diameters.

PURPOSE/HYPOTHESIS

The purpose was to biomechanically compare all-suture anchors and titanium suture anchors for distal biceps tendon repair in cadaveric specimens. The hypothesis was that all-suture anchors would show no differences in load to failure or displacement under cyclic loading compared with titanium suture anchors.

STUDY DESIGN

Controlled laboratory study.

METHODS

Sixteen unpaired, fresh-frozen human cadaveric elbows were randomized to 2 groups, which underwent onlay distal biceps tendon repair with 2 anchors. Bone mineral density at the radial tuberosity was evaluated in each specimen. In the first group, distal biceps tendon repair was performed using all-suture anchors. In the second group, titanium suture anchors were applied. After cyclic loading for 3000 cycles, the repair constructs were loaded to failure. The peak load to failure as well as repair construct stiffness and mode of failure were determined.

RESULTS

The mean (±SD) peak load was 293.53 ± 122.15 N for all-suture anchors and 280.02 ± 69.34 N for titanium suture anchors (P = .834); mean stiffness was 19.78 ± 2.95 N/mm and 19.30 ± 4.98 N/mm, respectively (P = .834). The mode of failure was anchor pullout for all specimens during load to failure. At the proximal position, all-suture anchors showed a displacement of 1.53 ± 0.80 mm, and titanium suture anchors showed a displacement of 0.81 ± 0.50 mm (P = .021) under cyclic loading. At the distal position, a displacement of 1.86 ± 1.04 mm for all-suture anchors and 1.53 ± 1.15 mm for titanium suture anchors was measured (P = .345). A positive correlation between bone mineral density and load to failure was observed (r = 0.605; P = .013).

CONCLUSION

All-suture anchors were biomechanically equivalent at time zero to titanium suture anchors for onlay distal biceps tendon repair. While the proximally placed all-suture anchors demonstrated greater displacement than titanium suture anchors, the comparable displacement at the distal position as well as the similar load and mechanism of failure make this difference unlikely to be clinically significant.

CLINICAL RELEVANCE

All-suture anchors performed similarly to titanium suture anchors for onlay distal biceps tendon repair at time zero and represent a reasonable alternative.

Biomechanics of the Proximal Radius Following Drilling of the Bicipital Tuberosity to Mimic Cortical Button Distal Biceps Repair Technique

BACKGROUND

A fracture through the proximal radius is a theoretical concern after cortical button distal biceps fixation in an active patient. The permanent, nonossified cortical defect and medullary tunnel is at risk during a fall eliciting rotational and compressive forces. We hypothesized that during simulated torsion and compression, in comparison with unaltered specimens, the cortical button distal biceps repair model would have decreased torsional and compressive strength and would fracture in the vicinity of the bicipital tuberosity bone tunnel.

METHODS

Sixteen fourth-generation composite radius Sawbones models were used in this controlled laboratory study. A bone tunnel was created through the bicipital tuberosity to mimic the exact bone tunnel, 8 mm near cortex and 3.2 mm far cortex, made for the BicepsButton distal biceps tendon repair. The radius was then prepared and mounted on either a torsional or compression testing device and compared with undrilled control specimens.

RESULTS

Compression tests resulted in average failure loads of 9015.2 N in controls versus 8253.25 N in drilled specimens ( P = .074). Torsional testing resulted in an average failure torque of 27.3 Nm in controls and 19.3 Nm in drilled specimens ( P = .024). Average fracture angle was 35.1° in controls versus 21.1° in drilled. Gross fracture patterns were similar in compression testing; however, in torsional testing all fractures occurred through the bone tunnel in the drilled group.

CONCLUSION

There are weaknesses in the vicinity of the bone tunnel in the proximal radius during biomechanical stress testing which may not be clinically relevant in nature.

CLINICAL RELEVANCE

In cortical button fixation, distal biceps repairs creates a permanent, nonossified cortical defect with tendon interposed in the bone tunnel, which can alter the biomechanical properties of the proximal radius during compressive and torsional loading.

Radiological and Clinical Evaluation of the Transosseous Cortical Button Technique in Distal Biceps Tendon Repair

PURPOSE

One of the options to repair a ruptured distal biceps tendon to the radial tuberosity is by means of a transosseous cortical button. Although excellent functional outcomes have been reported, no studies have been performed to quantify the effect of the transosseous fixation technique on the radius. Our study evaluated the clinical outcome and radiological outcome of this technique. The main goal of this study was to evaluate the radiographic evolution of the bone tunnel in the radius.

METHODS

Patients with an acute distal biceps tendon rupture treated with a transosseous cortical button were invited to take part in the study. Fourteen patients were included in the final analysis. All patients were evaluated both clinically and by computed tomography scanning of the proximal radius after a minimum follow-up of 2 years. Outcomes were recorded using the visual analog scale score for pain, the Mayo Elbow Performance Score, and Disabilities of the Arm, Shoulder, and Hand scores. Bone tunnel volume was measured with semiautomated computed tomography segmentation using image-processing software.

RESULTS

There were no failures of fixation in the patient group examined. Elbow mobility, arm, and forearm circumference were symmetric for all patients. Average visual analog scale for pain was less than 2. Mean Disabilities of the Arm, Shoulder, and Hand score and Mayo Elbow Performance Score were 2.3 and 97.6, respectively. Computed tomography images showed an average closure of the radial bony tunnel of 64% of the initial volume.

CONCLUSIONS

Biceps tendon repair with cortical button fixation only shows partial tunnel closure. This could reduce the risk of potential complications due to osteolysis, such as radius fracture or hardware failure. Functional results were excellent and comparable to other fixation methods. The role of interference screws in transosseous cortical button techniques to strengthen the repair and to avoid osteolysis may therefore be questioned.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Serial MRI evaluation following arthroscopic rotator cuff repair in double-row technique

INTRODUCTION

So far, recurrent rotator cuff defects are described to occur in the early postoperative period after arthroscopic repair. The aim of this study was to evaluate the musculotendinous structure of the supraspinatus, as well as bone marrow edema or osteolysis after arthroscopic double-row repair. Therefore, magnetic resonance (MR) images were performed at defined intervals up to 2 years postoperatively.

STUDY DESIGN

Case series; Level of evidence, 3.

MATERIALS AND METHODS

MR imaging was performed within 7 days, 3, 6, 12, 26, 52 and 108 weeks after surgery. All patients were operated using an arthroscopic modified suture bridge technique. Tendon integrity, tendon retraction ["foot-print-coverage" (FPC)], muscular atrophy and fatty infiltration (signal intensity analysis) were measured at all time points. Furthermore, postoperative bone marrow edema and signs of osteolysis were assessed.

RESULTS

MR images of 13 non-consecutive patients (6f/7m, ∅ age 61.05 ± 7.7 years) could be evaluated at all time points until ∅ 108 weeks postoperatively. 5/6 patients with recurrent defect at final follow-up displayed a time of failure between 12 and 24 months after surgery. Predominant mode of failure was medial cuff failures in 4/6 cases. The initial FPC increased significantly up to 2 years follow-up (p = 0.004). Evaluations of muscular atrophy or fatty infiltration were not significant different comparing the results of all time points (p > 0.05). Postoperative bone marrow edema disappeared completely at 6 months after surgery, whereas signs of osteolysis appeared at 3 months follow-up and increased to final follow-up.

CONCLUSIONS

Recurrent defects after arthroscopic reconstruction of supraspinatus tears in modified suture bridge technique seem to occur between 12 and 24 months after surgery. Serial MRI evaluation shows good muscle structure at all time points. Postoperative bone marrow edema disappears completely several months after surgery. Signs of osteolysis seem to appear caused by bio-absorbable anchor implantations.

Distal biceps tendon repair: comparison of clinical and radiological outcome between bioabsorbable and nonabsorbable screws

BACKGROUND

Distal biceps tendon repair to the radial tuberosity can be conducted by means of an interference screw in combination with a transosseous button. Bioabsorbable interference screws have been associated with complications such as severe osteolytic reactions. We questioned whether patients with a distal biceps tendon repair with bioabsorbable poly-L-lactide (PLLA) screws had different functional, clinical, and radiologic outcome than patients with nonabsorbable poly-ether ether ketone (PEEK) screws.

METHODS

Between 2010 and 2014, 23 patients with an acute distal biceps tendon rupture were treated with reinsertion of the distal biceps tendon in a bone tunnel at the radial tuberosity through a single anterior incision using a transosseous button combined with an interference screw. A PLLA screw was used in 12 patients and a PEEK screw in 11 patients. All patients were retrospectively evaluated with a minimal follow-up of 1 year clinically and by means of the visual analog scale for pain, Mayo Elbow Performance Score, and Disabilities of Arm, Shoulder and Hand Outcome Measure score. Bone tunnel volume was measured with computed tomography segmentation.

RESULTS

Elbow mobility and arm and forearm circumference were symmetric for all patients. The visual analog scale for pain was 0.2 in the PLLA group and 0.7 in the PEEK group. The Disabilities of Arm, Shoulder and Hand score and Mayo Elbow Performance Score were 5.4 and 98.7 in the PLLA group vs. 3.1 and 95.9 in the PEEK group. Bone tunnel enlargement of 43% in the PLLA and 38% in the PEEK group was noted.

CONCLUSIONS

Clinical and functional outcome at more than 1 year after distal biceps tendon repair was excellent in both groups. Bone tunnel widening occurred in all patients.

Surgical Treatment of Distal Biceps Ruptures

Distal biceps ruptures occur from eccentric loading of a flexed elbow. Patients treated nonoperatively have substantial loss of strength in elbow flexion and forearm supination. Surgical approaches include 1-incision and 2-incision techniques. Advances in surgical technology have facilitated the popularity of single-incision techniques through a small anterior incision. Recently, there is increased focus on the detailed anatomy of the distal biceps insertion and the importance of anatomic repair in restoring forearm supination strength. Excellent outcomes are expected with early repair of the distal biceps, with restoration of strength and endurance to near-normal levels with minimal to no loss of motion.

ISOKINETIC AND FUNCTIONAL EVALUATION OF DISTAL BICEPS RECONSTRUCTION USING THE MAYO MINI-DOUBLE ROUTE TECHNIQUE

OBJECTIVE

To evaluate the functional outcome among patients with distal biceps injuries who were operated using the Mayo mini-double route technique, with a minimum follow-up of six months after surgery, through digital isokinetic dynamometry, goniometry and subjective scores in order to establish objective and subjective improvement patterns and discuss the effectiveness of the procedure.

METHODS

Nine patients who underwent surgery to treat distal biceps injury were evaluated by means of Cybex digital dynamometry using an angular velocity of 30°/s with five repetitions and 120°/s with 15 repetitions, in comparison with the uninjured side. DASH (Disabilities of the arm, shoulder and hand), Mayo elbow score and conventional goniometry were also used.

RESULTS

Digital dynamometer showed that using the angular velocity of 30°/s with five repetitions, there was an average flexion deficit of 9.6% and an average supination deficit of -28.97%. Using an angular velocity of 120°/s with fifteen repetitions, the average flexion deficit was 4.43% and the average supination deficit was -24.1%.

CONCLUSIONS

The loss of flexion followed the pattern already shown in the literature. However, in our series, there were supination strength gains, possibly due to the strict rehabilitation protocol. The technique used in this study was safe and low-cost, with few complications and good functional results.

Graft osteolysis and recurrent instability after the Latarjet procedure performed with bioabsorbable screw fixation

HYPOTHESIS AND BACKGROUND

The Latarjet procedure is a reliable treatment of recurrent anterior shoulder instability. The coracoid process is usually fixed with metallic screws; however, these can lead to irritation and the necessity for hardware removal and also can produce artifacts on imaging studies. The use of resorbable screws could avoid these complications. The purpose of this study was to assess the clinical results of the Latarjet procedure performed with bioabsorbable screws in addition to healing of the graft and resorption of the screws.

METHODS

In 2009, we performed a prospective study (case series,

LEVEL OF EVIDENCE

IV) of 11 patients (12 shoulders) who underwent a Latarjet procedure fixed with resorbable screws. Each patient was observed clinically and had a computed tomography scan at 3 months and 2 years of follow-up.

RESULTS

Every graft healed at 3-month follow-up. At 2-year follow-up, 4 patients had at least one instability episode, and one underwent a revision surgery. Three of these 4 patients were unhappy or disappointed. The Walch-Duplay score was excellent or good for 7 shoulders and medium or poor for 5. Screw resorption appeared complete in every case. No drill hole enlargement was observed. Every drill hole was partially filled with bone. Of 12 shoulders, 8 (66.67%) were associated with a severe osteolysis and an almost complete disappearance of the graft.

CONCLUSION

Coracoid graft osteolysis, previously reported after the Latarjet procedure, appears to be exacerbated with a risk of complete disappearance of the graft when the procedure is performed with the bioabsorbable screws used in this study.

Low incidence of tendon rerupture after distal biceps repair by cortical button and interference screw

BACKGROUND

The use of cortical suspensory fixation in conjunction with an interference screw to treat distal biceps ruptures has yielded favorable results. However, literature examining the incidence of fixation failure in a large consecutive series of patients treated with this technique is lacking.

METHODS

A retrospective review of electronic medical records identified 170 distal biceps ruptures in 168 consecutive patients (164 men and 4 women) treated using a cortical button in conjunction with an interference screw. The study group was an average age of 48 years (range, 20-71 years). Records were reviewed from the time of the initial clinic visit to the most recent follow-up. Early failures were defined as those that occurred within 12 weeks of the index procedure. Failed repair was defined as tendon defect, deformity, or significant weakness in supination.

RESULTS

The early incidence of failure was 1.2%, with 2 of the fixations meeting the criteria for failure. One patient had significant brachial artery thrombosis. Other complications included posterior interosseous nerve palsy, lateral antebrachial cutaneous nerve-related complication, and numbness about the radial nerve.

CONCLUSION

The use of a cortical suspensory fixation device in conjunction with an interference screw is an effective method of repairing a distal biceps rupture, with a low early rate of failure.

The distal biceps tendon

Distal biceps tendon ruptures continue to be an important injury seen and treated by upper extremity surgeons. Since the mid-1980s, the emphasis has been placed on techniques that limit complications or improve initial tendon-to-bone fixation strength. Recently, basic science research has expanded the knowledge base regarding the biceps tendon structure, footprint anatomy, and biomechanics. Clinical data have further delineated the results of conservative and surgical management of both partial and complete tears in acute or chronic states. The current literature on the distal biceps tendon is described in detail.

Surgical Technique for Single and Double-Incision Method of Acute Distal Biceps Tendon Repair

Introduction

Distal biceps tendon ruptures can be repaired with either a single or a double-incision technique.

Step 1 Single-Incision Technique Surgical Exposure and Preparation of the Tendon

Through a single anterior incision, identify the tendon and debride the distal degenerated portion.

Step 2 Single-Incision Technique Preparation of the Radius

Expose the bicipital tuberosity and prepare the bone for insertion of suture anchors.

Step 3 Single-Incision Technique Tendon Reattachment

Suture the tendon with a reduction knot technique that allows for anatomic tendon apposition to bone.

Step 1 Double-Incision Technique Surgical Exposure and Preparation of the Tendon

Through a small anterior incision retrieve the tendon, debride the distal degenerated portion of the tendon, and place your sutures.

Step 2 Double-Incision Technique Preparation of the Radius

Through a second posterolateral incision, expose the biceps tuberosity and, using a burr, create a trough for the tendon.

Step 3 Double-Incision Technique Tendon Reattachment

Pass the sutures through the transosseous tunnels and tension the sutures, allowing the biceps tendon to be pulled into the trough created in the bicipital tuberosity, and then tie the sutures.

Step 4 Postoperative Care

Assess tension across the repaired tendon, initiate prophylaxis against heterotopic ossification, and begin rehabilitation.

Results

We recently conducted a prospective randomized controlled trial at our center comparing the single and double-incision techniques for the repair of acute distal biceps tendon ruptures¹¹.

What to Watch For

IndicationsContraindicationsPitfalls & Challenges.