Objectives. The long head of the biceps (LHB) is often resected in shoulder surgery and could therefore serve as a cell source for tissue engineering approaches in the shoulder. However, whether it represents a suitable cell source for regenerative approaches, both in the inflamed and non-inflamed states, remains unclear. In the present study, inflamed and native human LHBs were comparatively characterized for features of regeneration. Methods. In total, 22 resected LHB tendons were classified into inflamed samples (n = 11) and non-inflamed samples (n = 11). Proliferation potential and specific marker gene expression of primary LHB-derived cell cultures were analyzed. Multipotentiality, including osteogenic, adipogenic, chondrogenic, and tenogenic differentiation potential of both groups were compared under respective lineage-specific culture conditions. Results. Inflammation does not seem to affect the proliferation rate of the isolated tendon-derived stem cells (TDSCs) and the tenogenic marker gene expression. Cells from both groups showed an equivalent osteogenic, adipogenic, chondrogenic and tenogenic differentiation potential in histology and real-time polymerase chain reaction (RT-PCR) analysis. Conclusion. These results suggest that the LHB tendon might be a suitable cell source for regenerative approaches, both in inflamed and non-inflamed states. The LHB with and without tendinitis has been characterized as a novel source of TDSCs, which might facilitate treatment of degeneration and induction of regeneration in shoulder surgery. Cite this article: J. Schmalzl, P. Plumhoff, F. Gilbert, F. Gohlke, C. Konrads, U. Brunner, F. Jakob, R. Ebert, A. F. Steinert. Tendon-derived stem cells from the long head of the biceps tendon: Inflammation does not affect the regenerative potential. Bone Joint Res 2019;8:414–424. DOI: 10.1302/2046-3758.89.BJR-2018-0214.R2

Background:. Massive rotator cuff tear can cause functional disability due to instability and degenerative changes of the shoulder joint. In patients with massive irreparable rotator cuff tear, tendon transfer is often used as the salvage procedure. Latissimus dorsi and pectoris major transfer are technically demanding procedures and may incur complications. The biceps tendon transfer may provide a biologically superior tissue patch that improves the biomechanics of the shoulder joint in patients with irreparable rotator cuff tear. This study evaluated the functional outcomes of biceps tendon transfer for irreparable rotator cuff tear in 6 patients with two years and longer follow-up. Methods:. Between September 2006 and October 2011, 50 patients with 50 shoulders underwent surgical repair for MRI confirmed rotator cuff tear. Among them, six patients with massive irreparable rotator cuff tear were identified intraoperatively, and underwent proximal biceps tendon transfer to reconstruct the rotator cuff tear. The biceps tendon was tenodesed at the bicipital groove, and the proximal intra-articular portion of the biceps tendon was transected. The biceps graft was fanned out and the distal end fixed to the cancellous trough around the greater tuberosity with suture anchor. The anterior edge was sutured to the subscapularis and the posterior edge to the infraspinatus tendon or supraspinatus if present. Postoperative managements included sling protection and avoidance of strenuous exercises for 6 weeks, and then progressive rehabilitation until recovery. Results:. The evaluation parameters included VAS pain score, UCLA score, Constant score and AHES score, and X-rays of the shoulder. At follow-up of 25.3 ± 25.0 (range 22 to 63) months, the mean VAS pain score decreased from 9.3 ± 0.8 preoperatively to 1.7 ± 1.4 postoperatively (p < 0.001). All patients presented with significant improvements in pain and function of the shoulder for daily activities after surgery, however, only one patient achieved excellent results. There is no correlation of functional outcome with age, gender and body mass index. There was no infection or neurovascular complication. Discussion:. The biceps transfer provides soft tissue coverage of the humeral head, and restores the superior stability of the shoulder joint. The transferred biceps tendon also improves the mechanics and increases the compression force of the humeral head to the glenoid fossa. The results of the current study showed significant pain relief and improvement of shoulder function after biceps tendon transfer for irreparable rotator cuff tear. Conclusion:. Biceps tendon transfer is effective in the management of massive irreparable rotator cuff tear. The procedure is technically accessible with minimal surgical risks

Aims. The conventionally described mechanism of distal biceps tendon rupture (DBTR) is of a ‘considerable extension force suddenly applied to a resisting, actively flexed forearm’. This has been commonly paraphrased as an ‘eccentric contracture to a flexed elbow’. Both definitions have been frequently used in the literature with little objective analysis or citation. The aim of the present study was to use video footage of real time distal biceps ruptures to revisit and objectively define the mechanism of injury. Methods. An online search identified 61 videos reporting a DBTR. Videos were independently reviewed by three surgeons to assess forearm rotation, elbow flexion, shoulder position, and type of muscle contraction being exerted at the time of rupture. Prospective data on mechanism of injury and arm position was also collected concurrently for 22 consecutive patients diagnosed with an acute DBTR in order to corroborate the video analysis. Results. Four videos were excluded, leaving 57 for final analysis. Mechanisms of injury included deadlift, bicep curls, calisthenics, arm wrestling, heavy lifting, and boxing. In all, 98% of ruptures occurred with the arm in supination and 89% occurred at 0° to 10° of elbow flexion. Regarding muscle activity, 88% occurred during isometric contraction, 7% during eccentric contraction, and 5% during concentric contraction. Interobserver correlation scores were calculated as 0.66 to 0.89 using the free-marginal Fleiss Kappa tool. The prospectively collected patient data was consistent with the video analysis, with 82% of injuries occurring in supination and 95% in relative elbow extension. Conclusion. Contrary to the classically described injury mechanism, in this study the usual arm position during DBTR was forearm supination and elbow extension, and the muscle contraction was typically isometric. This was demonstrated for both video analysis and ‘real’ patients across a range of activities leading to rupture. Cite this article: Bone Jt Open 2022;3(10):826–831

Aim: To study mRNA expression in ruptured biceps tendon. Methods: Our study was carried out in the University College of Medicine. We took the biceps tendon of 5 patients who had traumatic ruptures. The age of the patients ranged from 35–53. The tendons were processed for RNA isolation and reverse-transcription-polymerase chain reaction (RT-PCR) carried out in order to investigate the mRNA gene expression in ruptured biceps tendon of extra cellular matrix (ECM) components (e.g. proteoglycans and collagens); ECM degradative components (e.g. aggrecanases and MMPs); inflammatory components (e.g. cytokines and cyclooxygenases); and factors involved in the apoptotic response. Results: Our results showed that in the samples of ruptured biceps tendon there was a good mRNA expression of ECM structural components, especially aggrecan and the small proteoglycans biglycan and decorin. Interestingly, these samples also showed a high expression for the enzymes commonly involved in articular cartilage degradation and turnover, the aggrecanases (ADAMTS-4 and –5) and the matrix metalloproteinases (MMP-3 and –13). As has been recently reported for Achilles tendon rupture (Cetti et al, 2003), an inflammatory reaction was also observed in these ruptured bicep tendons with expression of the inflammatory cytokines IL-1α and TNFα and the enzyme cyclooxygenase-2. Conclusion: We know clinically that patients can rupture their biceps tendon either due to trauma if not due to degenerative conditions. In our study we wanted to know if the subset of patients who ruptured their tendons traumatically had any pre-existing degenerative conditions leading on to the rupture compared to the normal subjects. Interestingly our study has shown that there is mRNA expression of degradative enzymes (aggrecanases and MMPs) in the samples of ruptured biceps tendon. Whether these mRNA levels equate to increased enzyme activity of these molecules warrants further investigation. Furthermore, our samples also showed mRNA expression for factors involved in the inflammatory response. In conclusion, mRNA expression of the factors involved in degradation and inflammation may suggest a phenotype that predisposes the bicep tendon to rupture, although further studies are required in order to investigate this further

Introduction: A cosmetic deformity does not always occur after a biceps tenotomy. The anatomical restraints preventing distal excursion of the long head of biceps tendon following tenotomy have not previously been described. This study aims to evaluate the biceps sheath and its potential role as a restraint to distal excursion of the biceps following tenotomy. Methods: Fifteen fresh cadaveric specimens were dissected free of overlying soft tissues to reveal the rotator cuff, biceps sheath and long head of biceps muscle belly and tendon. Eight specimens were used for gross anatomical analysis. Measurements of the length of the biceps sheath on the humeral (bone) side and tendon side were made using a digital caliper (Mitutoyo, Japan). The long head of biceps tendon was then released from the glenoid labrum and the excursion of the stump relative to the rim of the articular surface measured. The biceps sheaths of two specimens were used for histological analysis. Seven specimens were used for mechanical analysis. A humeral osteotomy was performed distal to the insertion of pectoralis major, leaving intact the biceps sheath and the muscle belly of long head of biceps. The proximal humerus was attached to a custom-designed jig and the muscle belly of biceps grasped in cryogenic grips. Specimens were loaded on an MTS 858 Bionix mechanical testing machine (MTS Systems, MN) in uniaxial tension at a rate of 1 mm/sec until failure was observed. Results: The biceps sheath surrounds the long head of biceps tendon and inserts into the bone of the proximal humerus. It is trapezoidal in cross-section, with a mean length of 75.1 mm on the bone side and 49.3 mm on the tendon side. The average excursion of the stump was to within 2.8 mm of the rim of the articular surface. Histological examination of the biceps sheath revealed membranous tissue consisting of loose soft tissue with fat and blood vessels. Synovial tissue was also identified. The sheath was seen to loosely attach to the biceps tendon, with a more intimate attachment to the periosteum. The mean force to pull the long head of biceps tendon out of the sheath 102.7 N (range 17.4 N–227.6 N). Discussion: The biceps sheath is a consistent structure intimately associated with the biceps tendon. It appears to contain blood vessels which provide nutrition to the tendon, similar to the vincula of flexor digitorum pro-fundus. Mechanical testing reveals that a substantial force is sometimes required to pull the biceps tendon from the sheath. This may explain why biceps tenotomy does not routinely result in a “Popeye” biceps

Repair of distal biceps tendon rupture is a subject that has received increasing attention in the past decade. In the active individual who desires as close to normal function as possible, repair of biceps tendon is recommended. The author describes a tehnique with a single anterior incision and fixation with superanchors. This method was successfully used in 25 patients with excellent functional results. There were no failures and no complications of neurological injury. The single anterior incision approach in which superanchors are used is recommended as an alternative to the traditional two-incision method. The Biceps brachii is an important flexor of the elbow and is the main supinator of the forearm. Avulsion of its distal tendon insertion is rare injury that mostly affects middle-aged men. It represents only 3% of all biceps tendon ruptures. There is an average of 1.24 spontaneous complete distal biceps ruptures per 100,000 people per year. The decline in the number of distal biceps tendon ruptures with increasing age correlates with a decrease in at-risk activities after the fourth decade of life. Decreased vascularity, tendon impingement, degenerative changes of the distal biceps tendon and the use of anabolic steroids have been postulated to predispose to tendon rupture. Our study shows that repair of distal biceps tendon ruptures using superanchors is safe and gives clinically objective and functional results similar to bone tunnel fixation. We had no major complications, no suture anchor failures and no occurrence of synostosis and neurological injuries. We recommend the use of superanchors for the treatment of distal biceps tendon ruptures

Previous studies describing drill trajectory for single incision distal biceps tendon repair suggest aiming ulnar and distal (Lo et al). This suggests that the starting point of the drill would be anterior and radial to the anatomic insertion of the distal biceps tendon. Restoration of the anatomic footprint may be important for restoration of normal strength, especially as full supination is approached. To determine the safest drill trajectory for preventing injury to the posterior interosseous nerve (PIN) when repairing the distal biceps tendon to the ANATOMIC footprint through a single-incision anterior approach utilising cortical button fixation. Through an anterior approach in ten cadaveric specimens, three drill holes were made in the radial tuberosity from the centre of the anatomic footprint with the forearm fully supinated. Holes were made in a 30º distal, transverse and 30º proximal direction. Each hole was made by angling the trajectory from an anterior to posterior and ulnar to radial direction leaving adequate bone on the ulnar side to accommodate an eight-millimetre tunnel. Proximity of each drill trajectory to the PIN was determined by making a second incision on the dorsum of the proximal forearm. A K-wire was passed through each hole and the distance between the PIN and K-wire measured for each trajectory. The PIN was closest to the trajectory K-wires drilled 30° distally (mean distance 5.4 mm), contacting the K-wire in three cases. The transverse drill trajectory resulted in contact with the PIN in one case (mean distance 7.6 mm). The proximal drill trajectory appeared safest with no PIN contact (mean distance 13.3 mm). This was statistically significant with a Friedman statistic of 15.05 (p value of 0.00054). When drilling from the anatomic footprint of the distal biceps tendon the PIN is furthest from a drill trajectory aimed proximally. The drill is aimed radially to minimise blowing out the ulnar cortex of the radius. For any reader inquiries, please contact . vansurgdoc@gmail.com

The functional importance of the long head of biceps tendon remains controversial, but it is well accepted as an important source of anterior shoulder pain. Both biceps tenotomy and tenodesis have well-documented results in the native shoulder. Management of the long head of biceps tendon during shoulder arthroplasty remains controversial. The existing literature supports surgical treatment of the biceps during shoulder arthroplasty. Walch et al. reported the largest series in multicenter study of over eight hundred shoulder arthroplasty patients with or without biceps tenodesis. The authors found more reproducible pain relief with biceps tenodesis and no difference in range of motion. Similarly, Soliman et al. reported on a prospective review of 37 patients undergoing hemiarthroplasty for fracture randomly assigned to biceps tenodesis vs. no treatment. The authors found a statistically significant improvement in Constant score and shoulder pain with biceps tenodesis. If left untreated during shoulder arthroplasty, the intact biceps tendon may be a source of anterior shoulder pain requiring revision surgery. Tuckman et al. reported excellent pain relief after biceps tenotomy or tenodesis for biceps-related pain after previous shoulder arthroplasty. The decision to perform a biceps tenotomy versus a tenodesis during shoulder arthroplasty also remains controversial. Tenotomy may increase the risk of cosmetic pop-eye deformity and muscle cramping or fatigue over tenodesis. Therefore, routine long head of biceps soft tissue tenodesis is recommended during shoulder arthroplasty as it safe, reproducible, cost-effective, associated with improved outcome scores, and minimises the risk of cosmetic deformity and pain associated with biceps tenotomy

Chronic distal biceps tendon rupture is a relatively uncommon situation with difficulties in treatment. Surgical treatment with allograft has been described in the literature with varying results. The purpose of this study was to describe 9 cases of chronic distal biceps tendon rupture which have been treated in our unit with local soft tissue as a graft. All patients were male with an average age of 54 years. The mean interval between tendon rupture and reconstruction was 11 months. In all patients a flap from lacertus fibrosus was used in continuation with the remnants of the tendon. The flap was entubulated and advanced to the bicipital tuberocity. The biceps was released and mobilized as necessary. In addition, 3 patients underwent a fractional lengthening of the muscle. All procedures were performed through a single anterior approach. Anchors and anchor sutures were used to stabilize the tendon to the tuberocity. The mean follow up was 3 years. No complications were encountered except for a superficial infection which resolved with oral antibiotics. All patients returned to their previous occupation. Furthermore, they all achieved 5/5 muscle strength regarding flexion and supination on manual testing. According to the Mayo Elbow performance score, the results were excellent in 8 patients, and fair in one. We believe that the aforementioned technique is useful in treating chronic biceps ruptures. It requires no additional cost and also the risk, even if marginal, of transmitting diseases with allografts, such Achilles tendon is avoided. Furthermore, the possibility of rerupture is minimal compared to the techniques using allograft or free autografts, since a revascularisation process during which the risk for failure is high does not take place as in other types of allografts

Rotator cuff or long head of biceps tendon tears are common in patients with degenerative shoulder rotator cuff disease. Most often they are investigated with an MRI scan. Diagnosis prior to surgery is useful for the appropriate surgical planning. We present 63 consecutive patients who had arthroscopic shoulder surgery and prior to that had MRI investigation between 1994 and 2001. Their medical records were reviewed; arthroscopic operative findings as well as the report of the MRI scan were recorded and compared retrospectively. The aim of our study was to assess the accuracy of MRI findings comparing the arthroscopic ones regarding rotator cuff and biceps tendon pathology. There were 63 patients with mean age 58 years. All of these had MRI scan investigation and the waiting time prior to surgery was 10 months. It was found that there were 6 false (−)ve, 1 false (+)ve and two cases with full thickness cuff tears which were reported as probable tears. Further to that, there were 11 frayed biceps tendons, 8 partially ruptured, 3 subluxed, 4 complete ruptures and 1 SLAP lesion. All biceps lesions were not commented in the MRI scan reports. MRI scan is very sensitive detecting soft tissue pathology in shoulder investigation. However, even on that basis, rotator cuff and in particular biceps tendon pathology can be missed. The shoulder arthroscopy is the best method to accurately diagnose those lesions. However, it should be noted that often the surgeon has got to alter to working surgical plan in order to address the problem intraoperatively. In this study it is demonstrated the MRI scan often misses rotator cuff or long head of biceps tendon pathology. The most sensitive method for the diagnosis of it is the shoulder arthroscopy, which address its treatment in the same time

Acute distal biceps tendon repair reduces fatigue-related pain and minimises loss of forearm supination and elbow flexion strength. We report the short- and long-term outcome following repair using an EndoButton technique. Between 2010 – 2018, 102 patients (101 males; mean age 43 years) underwent acute (□6 weeks) distal biceps tendon repair using an EndoButton technique. The primary short-term outcome was complications. The primary long-term outcome was the Quick-DASH (Q-DASH). Secondary outcomes included the Oxford Elbow Score (OES), EuroQol-5D-3L (EQ-5D), return to function and satisfaction. At mean short-term follow-up of 4 months (2.0 – 55.5) eight patients (7.8%) experienced a major complication and 34 patients (33.3%) experienced a minor complication. Major complications included re-rupture (n=3, 2.9%), unrecovered nerve injury (n=4, 3.9%) and surgery for heterotopic ossification excision (n=1, 1.0%). Three patients (2.9%) required surgery for a complication. Minor complications included neuropraxia (n=27, 26.5%) and superficial infection (n=7, 6.9%). At mean follow-up of 5 years (1 – 9.8) outcomes were collected from 86 patients (84.3%). The median Q-DASH, OES, EQ-5D and satisfaction scores were 1.2 (IQR 0 – 5.1), 48 (IQR, 46 – 48), 0.80 (IQR, 0.72 – 1.0) and 100/100 (IQR, 90 – 100) respectively. Most patients returned to sport (82.3%) and employment (97.6%) following surgery. Unrecovered nerve injury was associated with a poor outcome according to the Q-DASH (p< 0.001), although re-rupture and further surgery were not (p > 0.05). Acute distal biceps tendon repair using an EndoButton technique results in excellent patient reported outcomes and health-related quality of life. Although rare, unrecovered nerve injury adversely affects outcome

Introduction. Tendon ruptures are a common injury and often require surgical intervention to heal. A refixation is commonly performed with high-strength suture material. However, slipping of the thread is unavoidable even at 7 knots potentially leading to reduced compression of the sutured tendon at its footprint. This study aimed to evaluate the biomechanical properties and effectiveness of a novel dynamic high-strength suture, featuring self-tightening properties. Method. Distal biceps tendon rupture tenotomies and subsequent repairs were performed in sixteen paired human forearms using either conventional or the novel dynamic high-strength sutures in a paired design. Each tendon repair utilized an intramedullary biceps button for radial fixation. Biomechanical testing aimed to simulate an aggressive postoperative rehabilitation protocol stressing the repaired constructs. For that purpose, each specimen underwent in nine sequential days a daily mobilization over 300 cycles under 0-50 N loading, followed by a final destructive test. Result. After the ninth day of cyclic loading, specimens treated with the dynamic suture exhibited significantly less tendon elongation at both proximal and distal measurement sites (-0.569±2.734 mm and 0.681±1.871 mm) compared to the conventional suture group (4.506±2.169 mm and 3.575±1.716 mm), p=0.003/p<0.002. Gap formation at the bone-tendon interface was significantly lower following suturing using dynamic suture (2.0±1.6 mm) compared to conventional suture (4.5±2.2 mm), p=0.04. The maximum load at failure was similar in both treatment groups (dynamic suture: 374± 159 N; conventional suture: 379± 154 N), p=0.925. The predominant failure mechanism was breakout of the button from the bone (dynamic suture: 5/8; conventional suture: 6/8), followed by suture rupturing, suture unraveling and tendon cut-through. Conclusion. From a biomechanical perspective, the novel dynamic high-strength suture demonstrated higher resistance against gap formation at the bone tendon interface compared to the conventional suture, which may contribute to better postoperative tendon integrity and potentially quicker functional recovery in the clinical setting

The clinical results of acute repair rupture of the biceps tendon insertion using a two incision Boyd Anderson approach in four patients are described. Four patients underwent acute biceps tendon repair using the Boyd Anderson approach and the tendon was secured to its anatomical insertion using a number 5 non-absorbable suture. One patient was immobilised in the postoperative period and the subsequent patients were allowed early mobilisation supervised by the physiotherapist. All patients were male and surgery was performed within three weeks of the injury. Two patients sustained injury playing rugby, one was injured lifting a bag of coal and one was injured lifting a motorised Go Kart. In all four cases the tendon was found to be avulsed from its bony insertion rather than ruptured in it’s mid substance or musculo-tendinous junction. There were no problems with wound break down or discomfort. The patient who was immobilised took longer to regain full range of extension, pronation and supination. All patients returned to the pre-injury employment, sporting and social levels. Our results suggest that early two incision approach and repair is associated with good functional outcome and minimal morbidity in the post operative phase

Introduction and Aims: Chronic distal biceps tendon ruptures have traditionally been treated with a biceps to brachialis tenodesis. The use of a semitendinosus autograft to reconstruct the distal biceps tendon for chronic rupture has been described. This study evaluates the functional outcome of a group of patients treated with autograft reconstruction. Method: This retrospective study identified six patients who underwent a late reconstruction of a biceps tendon rupture using a semitendinosis autograft. Functional outcome was evaluated objectively and subjectively. Clinical subjective evaluation included the MAYO elbow score and the outcome questionnaire from the Society of Shoulder and Elbow Surgeons (SSES). Objective outcomes were assessed by measurement of peak torque for both elbow flexion and supination using a Cybex II Isokinetic machine. Comparisons were made with the opposite limb. Results: Six right-handed male patients aged 42±7 yrs (range 34–48 yrs) were evaluated in this study, five of which achieved a good to excellent MAYO performance score (average 87 ±12), and SSES score (average 86±21). Peak torque obtained during maximal elbow flexion was 44±17 Nm (vs. 55 ±16 Nm opposite elbow) during supination was 8±4Nm (vs. 10±2Nm opposite elbow). Conclusion: This study represents a series of patients with autograft reconstruction of the chronic distal biceps rupture. It is the first study to quantitatively measure the recovery of strength of elbow flexion and supination. The semitendinosus autograft provides a strong and reliable reconstructive option in the majority of patients with chronic biceps tendon ruptures. Recovery of elbow flexion and supination power is nearly normal

Distal biceps tendon ruptures are uncommon with a reported incidence of 1.24 per 100,000 per year. They typically occur in males in the fourth decade. Operative treatment has been shown to improve functional outcomes in the treatment of distal biceps tendon ruptures. A variety of surgical techniques have been described, usually using the dual incision Boyd-Anderson approach. We report a series of 10 patients with 10 tendon ruptures treated using a single incision volar approach and using the Arthrex Biotenodesis screw to reattach the tendon to the radial tuberosity. This method has been previously described in only one case report. All ten patients underwent clinical assessment using the Mayo Elbow Performance Score (MEPS) and functional assessment using the DASH scoring system. The power was assessed isokinetically using the Nottingham Myometer. Based on the MEPS and DASH grading system all patients achieved a good or excellent result. In our experience reattachment of the distal biceps tendon using a single incision approach and Arthrex Biotenodesis screw is a new technique which gives a good functional outcome

Aim: The biceps brachii is an important elbow flexor and is the main supinator of the forearm. Avulsion of its distal tendon insertion is an uncommon injury and even more uncommon is the partial tear of this tendon. The rupture typically occurs at its attachment to the radial tuberosity. Nonoperative treatment of these injuries has been described, but significant weakness in flexion and supination or persistent pain may occur. Most authors recommend acute anatomic repair to improve function or relieve pain. Material and Method: Twenty-five ruptures of the distal biceps tendon were operated at our institution from 1992 to 1997. Twenty-three of the patients were male and 2 female. The dominant extremity was involved in 21 patients. Their average age was 48 years (range, 30–59). Eighteen ruptures were complete, 8 of them were acute, while 10 were chronic, as were the 7 partial ruptures. Three patients with complete rupture and all the patients with partial rupture had a MRI. In 2 chronic patients an anatomic repair was impossible and they were treated with a biceps-to-brachialis transfer. These patients were not included in the final follow-up. All other tendons were repaired anatomically through use of a single anterior incision and bone suture anchors. Follow-up averaged 36 months (range, 12–53 months). At final follow-up subjective and objective data were collected. Patients were questioned about their activity level, job status, and satisfaction at outcome. Elbow range of motion, strength and power were compared with those for the uninjured side while each value was adjusted for dominance and expressed as a percentage of the uninjured side. Results: All patients returned to their preinjury level of activity and employment by 6 months after surgery. All patients reported that they were satisfied with the result and would undergo the surgery again. The entire group of patients averaged 9.8% more flexion strength and 2.4% less supination strength for the repaired elbow that for the uninvolved elbow. Range of motion was normal in 20 patients. Three patients lacked 10° of extension and one of them lacked 10° of pronation. No patient experienced transient or permanent nerve deficit. None of the patients complained of pain or tenderness. There was no evidence of heterotopic ossification or change in the position of the suture anchors. Conclusion: The one incision technique with bone suture anchors is a safe and reliable technique for the treatment of complete or partial distal biceps tendon ruptures with very good results referring to restoration of flexion and supination strength and minimal complication rate

Purpose: Anatomic repair of an acute distal biceps tear has been demonstrated to improve flexion and supination strength compared with conservative treatment. The most commonly used fixation methods for a distal biceps tendon repair include suture anchors, bioabsorbable screws, and endobutton. The goal of this study was to. perform a radiologic evaluation of bioabsorbable screw tunnel osteolysis and. retrospectively review bioabsorbable-screw related clinical complications. Method: We included twenty (20) consecutive patients who underwent primary anatomic repair of the distal biceps tendon since 2005. We used a 7x23mm biote-nodesis. ®. screw (Arthrex) in 18 cases, and 8x23mm and 8x12mm screws in the other two cases. First, from the x-ray view done in the immediate postoperative period showing the complete screw tunnel, we measured the ratio of the volume of the bone tunnel to the volume of the radius bone section. A mathematical formula for cylindrical volume was used (¶ x r2 x h). We used a relation between two volumes rather than the tunnel volume itself for scaling purposes. Secondly, we calculated the same relation on the x-ray from the last follow-up. We then obtained the percentage of tunnel enlargement by relating the volumetric ratio from the first x-ray to the ratio from the last x-ray. Afterwards, we performed a retrospective chart review noting any bioabsorbable screw-related and postoperative complications. Results: In the group, the average age was forty-six (46) years. All subjects were male. Eighteen (18) cases were acute complete ruptures operated in the first three weeks, one case was a partial rupture and one case was chronic (one year). The average follow up was eighteen (18) months. We found that the average initial relative volume occupied by the screw tunnel was 47 % of the bone section. At the last follow-up, this volume increased to 68%. After our chart review, we found that one patient presented with a broken screw and increased pain and that another patient developed a severe foreign-body reaction with re-rupture of the tendon requiring three reoperations. Conclusion: The use of a bioabsorbable screw for distal biceps tendon fixation results in significant osteolysis of the radial bone at short term follow-up. Consequences of osteolysis in the radius are worrisome since iatro-genic fractures are more likely to occur. Osteolysis can be secondary to an inflammatory reaction to the screw material, bone necrosis secondary to pressure or initial thermal necrosis. We also noted two cases of severe bio-tenodesis screw-related complications among our series of twenty (20) patients. These results call into question the use of the bioabsorbable screw in distal biceps tendon repair and are important to present. Exact volume of bone loss using 3D computed tomography scan analysis as well as quality of life questionnaires and strength testing will be available for presentation

Introduction: Proximal radio-ulnar synostosis is a rare complication after distal biceps tendon repair. Synostosis results in usually painfree limitation of forearm rotation and loss of function. The outcome after synostosis excision has not been demonstrated. Methods: Between 1987 and 2003 twelve patients were identified with radio-ulnar synostosis and retrospectively reviewed clinically and radiographically. All patients initially experienced a complete distal biceps tendon rupture after lifting heavy objects. The average time to repair was fourteen days. Results: These twelve patients underwent excision of synostosis as early as two months post repair and as late as 18 months. The average age at time of excision was forty-five years and the dominant arm involved in seven patients. All received postoperative idomethacin for four weeks and only six received additional postoperative irradiation. The average follow-up was fifty-nine months. Function revealed an average pre-operative rotational arc of 19, six patients were ankylosed in a neutral position. The postoperative arc was 138 (p = 0.007). Flexion and extension was essentially normal preoperatively and postoperatively. All twelve patients demonstrated no pain pre- and postoperatively. All patients were very satisfied with the result. There were no complications after excision. Radiographically there was no recurrence of ectopic bone formation. Discussion and Conclusion: Excision of proximal radio-ulnar synostosis following distal biceps repair results in a significant improvement of limited forearm rotation and returning patients to a pain free functional rotational arc with a high satisfaction rate

PURPOSE: We describe the results of 64 patients who underwent treatment for acute distal biceps tendon rupture using a single incision and suture anchors. The purpose of the study is to evaluate if this method is reliable and if it can reduse the risk of ectopic bone formation or synostosis. Methods: 64 patients underwent surgical repair for acute rupture of the distal biceps tendon, using suture anchors and a single incision. All performed by 1 surgeon. We had 63 male and 1 female with a mean age of 48 years (range 30–59). Our operative technique consisted of an “S”-shaped anterior incision centered over the antecubital fossa. After identification and protection of the lateral antebrachial cutaneous nerve, we exposed and mobilized the ruptured biceps tendon. The distal portion of the tendon was debrided and the radial tuberosity gently decorticated. A 4 stranded suture was then inserted into the tuberosity. The tendon was advanced to bone and the sutures were tied using the modification of Kessler’s technique, holding the elbow in 90° of flexion. The post-op protocol was a posterior splint for 10 days (in 90° of flexion and 20° of supination), a dynamic hinged-extension block brace in 45° for 3 weeks and progressive advancement to full extension in 3 more weeks. Strengthening exercises were permitted after 3 months. Results: All acute tears (< 3 weeks) were repaired anatomically. The follow-up period was 39 months (range 18m – 11years). Objective data consisted of ROM (range of motion) of the elbow, flexion and supination strength were measured by a BTE Work Stimulator. The ROM was normal in 54 patients, 10 patients lacked 10° of extension. 51 patients returned to their pre-injury level of activity and within 6 months returned to work. All patients reported pain relief and good recovery of strength and were completely satisfied of the outcome. There were no implant failures, nerve palsies or heterotopic bone formation. Conclusions: Use of a single incision repair with bone suture anchors provides secure fixation of distal biceps tendon to the radius with minimal volar dissection wich is associated with a minimum risk of synostosis and posterior interosseous nerve injuries. This method is reliable for acute ruptures. Return to normal strength and range of motion can be expected if tendon repair is performed before 3 weeks. The advantages of this method are less dissection for re-attachment of the tendon, less nerve injuries and no ectopic bone formation or synostosis

Introduction and objective: Distal biceps tendon ruptures commonly occur in the dominant arm of male between 40 and 60 years of age. The degenerative tendon avulses from the radial tuberosity. Conservative treatment results in decreased flexion and supination strength. Surgical reattachment is the treatment of choice and several surgical approaches and fixation devices have been proposed. The purpose of this study was to compare the results of two different techniques. Materials and Methods: Twenty-four consecutive patients with distal biceps tendon ruptures were randomly assigned to one of two treatment groups: 12 using 2 biodegradable anchors through a modified 2-incision technique (group A) and 12 patients underwent distal biceps repair using an Endobutton. ®. (Acufex Smith & Nephew, Andover MA) using a single transverse anterior incision (group B). All patients were male. Average age was 40 (33–57) in groupA and 42 (29–59) in group B. The rupture was located in the dominant arm in 6 patients in groupA and 7 in group B. The interval between injury and surgery was similar in both groups (< 12 days). Postoperative protocol and rehabilitation was the same in both groups. Full range of motion as tolerated was allowed two week after surgery. Active range of motion, Mayo Elbow Performance Score (MEPS), pain, strength (Dexter isokinetic testing), patient satisfaction, operative time and elbow radiographs were evaluated at 12 months postoperatively. The mean follow-up was 17 months (range, 12–34). Results: Average operative time (minutes):50 (group A) and 42 (group B). There were no complications in group B. Two patients in group A had a transient posterior interosseous nerve neurapraxia with spontaneous full recovery after 3 months, and other one developed symptomatic heterotopic bone formation and synostosis was resected. There was no statistical significant difference in MEPS score, range of motion, time to return to work or strength between both groups. All patients in both groups were satisfied with their final result and eventually returned to their pre-injury activity level without sequelae after 12.2 (group A) and 10.3 (group B) weeks. Conclusion: Functional results of the two techniques studied were similar. Anterior approach showed lesser complications and less time off work than 2-incision technique. Endobutton. ®. single approach assisted tecnique should be considered the gold standard procedure for distal biceps tendon repair due to its shorter operative time and lower morbidity. However, we need series with a longer follow-up to confirm these results