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.

PURPOSE: We describe a new technique for the treatment of painful instability of the distal ulna after Darrach procedure using an allograft as a mechanical interposition. The purpose of the study is to evaluate the results of this technique.

Methods: In this study we report on 17 patients who underwent revision of their Darrach procedure using an allograft (human Achilles tendon allograft). The average age of the patients was 47 years (range 39–68) and the average time after the original procedure was 15 months. The indication for the revision surgery in all patients was incapacitating pain over the distal stump of the ulna which increased during pronation or supination and with active grip. Pain was assessed using a VAS (Visual Analog Scale). Grip strength was measured using a dynamometer. All patients had instability of the distal ulna, and crepitus or palpable “clicking” during forearm rotation. Radiographs of all patients demonstrated erosion of the medial cortex of the radius, indicating impingment.

Technique: 2 or 3 suture anchors were placed into the medial cortex of the radius, proximal to the sigmoid notch where the impingment occurred. An adequate amount of the allograft was then sutured into an anchovy. The size of the allograft was determined by pronating and supinating the involved forearm with pressure applied to the ulnar aspect of the ulna to assess crepitus. Sutures were placed through the allograft, creating a pillow-shaped spacer. Two or three drill holes were then placed into the distal ulna for fixation of the allograft to the ulna. With final allograft placement there should be significant padding between the radius and the ulna to prevent any palpable crepitus during forearm rotation under compression.

Results: After an average follow-up time of 34 months all patients were re-evaluated by subjective assessment, range of motion, grip strength, pain relief and radiographs. We report 16 patients with good and excellent results and 1 patient with persistent complaints (our first patient). There were no radiographic changes noted.

Conclusions: The use of an allograft as a mechanical interposition between the radius and the ulna has not been described previously. With this technique there is no need for a metallic prosthesis and as much bulk graft as necessary is obtainable. We believe that this technique is an excellent alternative to metal arthroplasty for reconstruction of difficult cases of failed distal ulna resection.

PURPOSE: Trapezial excision with ligament reconstruction combined with tendon interposition has proven to be a highly effective technique for the treatment of OA of the CMC joint. We believe the same procedure is possible with use of modern orthobiologics.

Methods: 35 patients underwent surgical treatment for CMC arthritis with a new technique using Graft Jacket (Wright Med.) instead of FCR. Graft Jacket is an acellular human collagen (dermis) allograft. It is rapidly revascularized, repopulated with host cells and has high tensile strength.

Technique: The Graft Jacket was rehydrated and cut to create a 15cm strip. It was then placed around or sutured to the FCR (the anchor) and passed into the intramedullary cavity of the metacarpal as in the standard LRTI procedure. The remaining Graft Jacket is sutured together as an anchovy to fill the former trapezium gap, so that both suspension and interposition occurred. The mean age of the patients was 56 years and the median follow-up period was 1 year. All patients had marked pain and radiographic evidence of severe arthritis before surgery. Pain, grip and pinch (tip and key) strength, stability and range of motion were measured pre- and post-operatively. Pain was assessed on a VAS (Visual Analog Scale). The ability to perform ADLs (Activities of Daily Living) requiring use of the thumb and to return to work were analyzed as well. Following surgery all thumbs were immobilized in a static splint for 10 days and then were placed into a removable orthoplast splint for 4–6 weeks. Radiographic examination was performed in all patients at the 10th post-op day, and also at 2 and 6 months after surgery.

Results: Significants improvements were seen with grip strength (average 25lb) and tip (average 3.5lb) and key (average 4.5lb) pinch strength as well as palmar and radial abduction (average 25o). Pain was significantly reduced with an average of 6.0 on the VAS. There were no foreign body reactions or other infections in our series.

Conclusions: This study showed that excellent results can be achieved in strength, pain reduction, range of motion and ADLs with this new technique in which Graft Jacket was utilized instead of FCR in ligament reconstruction and interposition arthroplasty of the CMC joint. Our results indicate less morbidity than with use of FCR (swelling, ecchymosis or weakness) with excellent final outcomes.

The results of surgical treatment of post-traumatic elbow contractures in adolescence have been conflicting in the literature. Some authors suggest that contracture release in this age group is less predictable and results less favorable than in adults. A retrospective review of the senior author’s patients produced 16 patients under the age of 21 that had post-traumatic elbow contracture releases. Three patients with arthroscopic releases and one patient lost to follow up were excluded from this study.

Twelve adolescent patients (mean age 16.7 years, range 13–21) had open release of post-traumatic elbow contractures. All releases were initiated through a lateral approach with anterior capsular release and were supplemented by posterior release (in 4 patients) through the same incision. Medial-sided pathology was addressed through a separate medial incision in 3 patients. In three patients the radial head was excised. Muscle lengthening was used in only one patient.

The mean follow-up was 18.9 months (range 10–42 months). Preoperative flexion was increased from 113 to 129deg (p< 0.01), extension from −51 to −15deg (p< 0.001) for a mean total gain of 54deg in the flexion-extension arc (p< 0.001). Pronation was improved from 58 to 77deg and supination from 56 to 62deg, but these improvements did not reach statistical significance. At the final follow-up the patients maintained 93% of the motion that was achieved intraoperatively. All patients achieved a functional ROM of at least 100deg in the flexion-extension arc. No patient lost motion. One patient had a superficial infection that was treated conservatively

Our experience with post-traumatic contracture release in adolescent patients has been rewarding; all patients reached a functional range of motion. The advantage of the lateral approach used in these patients is that it allows simple and safe access to the anterior capsule, which is often adequate to regain full extension. Through the same approach the posterior structures can also be addressed without violating the lateral collateral ligament. The medial approach is more demanding and was reserved only for patients with medial sided pathology. Fractional musculotendinous lengthening was rarely necessary in post-traumatic contractures. Open release in adolescent patients with congruent stiff elbows has yielded satisfactory results in our hands.

Despite the widespread use of demineralized bone matrix (DBM) allografts there are few clinical studies comparing DBM to iliac crest bone grafting (ICBG). A comparison of DBM to ICBG is presented in patients who underwent four corner fusions of the wrist by one surgeon using identical operating technique.

The senior author’s first fourteen consecutive patients in which DBM was used for four corner fusion were compared with fourteen patients selected from a total of 48 patients in which ICBG was used. The ICBG group was matched for age, indication and healing impairing co-morbidities (mainly smoking). Patient radiographs from the 8th, 12th and 24th postoperative week follow up were digitized and blinded. Three orthopaedic surgeons, not involved in the patients care, rated the degree of bony union in a scale of 0 (no evidence of healing) to 3 (solid bony healing). The operating technique and fixation was identical in all patients. K-wires were removed at a mean of 8.2 weeks for DBM and 7.7 weeks for the ICBG group.

All patients had a minimum follow-up of one year. All fusions healed both radiographically and clinically without complications. Review of the radiographs revealed significantly less visible healing at 8 weeks in the DBM group (mean score 1.50 versus 1.74 of the ICBG group, p< .05). Lower scores were also obtained for the DBM group at 12 and 24 weeks but they did not reach statistical significance.

In this study both DBM and ICBG were equally effective in achieving solid bone union for intercarpal fusions. However, the statistical power of this series is not adequate to conclude that healing rates are equal between the two graft materials. The radiographic appearance of bridging bone lagged behind in the DBM group. The biological significance of this finding is not clear; it could indicate delayed mineralization at the fusion site. Such a delay may be significant in graft choice for patients with healing impairment.

Arthroscopic debridement and pinning is not considered to be effective in dynamic scapholunate (SL) instability treated more than three months post injury; open procedures (capsulodesis, tenondesis, SL ligament reconstruction, intercarpal fusions) are preferred for these patients. The best procedure for this problem is yet to be determined. A restrospective review of the senior author’s records produced thirteen patients with late presenting dynamic SL instability who were unwilling to undergo an open procedure and were treated initially with aggressive arthroscopic debridement and pinning. The mid-term results of this approach are presented.

Eleven of the initial thirteen patients were available for follow-up. Their mean age was 36 years (range 23–50) and the mean time elapsed from injury was 7 months (range 4.5–10). The diagnosis of dynamic SL instability was based on a positive Watson’s test, SL gapping on grip view radiographs and arthroscopic findings of a Geissler type III (in 5 patients) or type IV (in 6 patients) SL tear. The SL angle was under 550 in all patients. The procedure included aggressive arthroscopic debridement of the torn portion of the SL ligament to bleeding bone in an effort to induce scar formation in the SL interval. The SL interval was subsequently reduced and pinned (with 2 pins through the SL and one pin in the scaphocapitate joint) under fluoroscopy. The pins were removed at a mean of 9.6 weeks (range 8–14).

The mean follow-up was 36 months (range 12–76). Three patients were re-operated at 9, 10 and 11 months after the initial procedure. Re-operations included a dorsal capsulodesis, a four-corner fusion and a wrist arthrodesis. The eight remaining patients achieved two excellent, four good, one fair and one poor result with the Mayo wrist score. Patients diagnosed with Geissler III tears were found to be younger and achieved better final wrist score (mean 86 points versus 76 points in patients with Geissler IV tears). Two pin track infections were treated conservatively.

Late (more than three months post injury) arthroscopic debridement and pinning was found to be only moderately successful for dynamic SL instability (6 out of 11 patients achieved a good or excellent result without re-operation). This approach, however, does not preclude subsequent open surgery. It is best suited for patients with Geissler type III tears (not a gross drive through sign) who are unwilling to undergo an extensive open procedure provided they understand the risks and benefits of this approach.

Distal biceps tendon rupture can lead, if left untreated, to substantial and appreciated decline of elbow flexion and forearm supination strength. In chronic cases (seen more than 6 weeks after injury) retraction of the muscle can render reattachment of the tendon to the bicipital tuberosity impossible. In this setting non-anatomic attachment of the biceps to the underlying brachialis is usually elected but this is not suitable for patients with high functional demands.

Eight male patients (mean age 40 years, range 30–52 years) with chronic distal biceps ruptures (mean time from injury 28 weeks, range 12–38 weeks) underwent distal biceps reconstruction. Five patients presented with pain and weakness during elbow loading (four with lateral antebrachial cutaneus (LAC) nerve distribution dysesthesias) and three with weakness alone. Indications for distal biceps reconstruction were a) inability to approximate the tendon stump to the bicipital tuberosity with the elbow in less than 700 of flexion after relaxing incisions to the epimysium were made and b) high functional demands in pronosupination in the patients occupation or recreational activities.

In the first patient in this series autologous fascia latta was used for reconstruction and in the seven subsequent patients an Achilles tendon allograft. Through an one-incision anterior approach the graft was secured to the biceps remnant and was attached to the bicipital tuberosity using suture anchors.

The mean follow up was 32 months (range 14–48 months). All patients were pain free and had returned to their previous occupation. Mean elbow flexion was 145 deg with an extension deficit of 10 deg observed in only one patient. The mean pronosupination was 170 deg. All patients had 5/5 strength of elbow flexion and supination on manual testing. Subjective weakness in supination was reported by one patient. The mean supination strength (tested using a BTE Work Simulator) was 87% of the contrallateral healthy extremity. Seven achieved an excellent and one a good rating in the Mayo elbow performance score. No complications were encountered.

Distal biceps reconstruction with Achilles tendon allograft using a one incision technique and suture anchors for reattachment provides an excellent alternative to non- anatomic repair in patients with a chronic retracted distal biceps rupture. Patients involved in activities that require strength in supination are most likely to benefit from this reconstruction.

Introduction: When possible direct repair of the chronic distal biceps tendon ruptures is recommended because the results of chronic repairs with grafts have traditionally not been as successful. Some key surgical tips will allow successful direct repair as it is noted in our series.

Material and Methods: Sixteen males with a chronic (6–14 weeks post injury) distal biceps rupture were repaired with the one-incision technique and 2 suture anchors. Average follow-up was 38 (range, 23–48) months. Involved arm was the dominant in 14 patients. The patients were assessed with the DASH questionnaire, goniometric range of motion and isokinetic strength testing of elbow flexion and supination. The position of the suture anchors was also evaluated radiographically. Surgical tips: 1) release adhesions between biceps and brachiallis, 2) release the bicipital aponeurosis, 3) “tease” the retracted tendon out of scar, 4) release the superficial biceps fascia and place relaxing incisions in the epimysium, 5) apply a surgical clamp to the end of the tendon and pull distally for 10–20 minutes. Note that the lateral antebrachial cutaneous nerve is frequently entrapped in scar and requires neurolysis.

Results: All patients regained almost normal flexion and supination strength, with a deficit of 12% and 15% respectively, compared with the uninvolved arm. Six patients had an average loss of extension of 120 (range, 50–180). According to the DASH test all patients had an excellent/good result (12 excellent, 4 good). X-rays revealed unchanged position of the anchors. No complications were noted.

Discussion-Conclusions: The use of flexor carpiradialis and of fascia lata that was used in several studies for repair of chronic distal biceps tendon ruptures has given controversial results mainly due to enlongation and inferior strength of the graft. Based on our results we believe that chronic (6–14 weeks post injury) distal biceps tendon ruptures can be successfully repaired through an anterior approach with direct repair and the use of suture anchors, avoiding the use of a graft.

Introduction: Currently the standard of care is to repair distal biceps tendon ruptures, particularly in active individuals. Although several studies have reported short-term good results with the one-incision technique none has report long-term results.

Material and Methods: Thirty- four male with distal biceps rupture were treated with an average follow-up of 5 (range,2–9) years. Involved arm was dominant in 28 patients. 22 ruptures were repaired acutely (less than 6 weeks from injury) and 12 had a late repair. The patients were assessed with the DASH questionnaire, goniometric range of motion and isokinetic strength testing of elbow flexion and supination. The position of the suture anchors was also evaluated radiographically.

Results: Patients with acute repair (82%) regained excellent flexion and supination strength, 108% and 99% respectively, compared with the uninvolved (usually nondominant) arm. Patients (18%) with chronic rupture repair had a slight deficit of supination (15%) and flexion (13%) strength. An average of 120 (range, 00–180) lack of extension was noted in the chronic tears while flexion/extension arc of the acute repairs was normal. With the exception of 4(12%) patients who returned to lighter work activities all patients return to their previous occupation. According to the DASH test all patients had an excellent/good result (28 excellent 6 good). X-rays revealed unchanged position of the anchors. No complications were noted.

Discussion-Conclusions: As in short-term results, long-term results of distal biceps tendon repair with the one-incision technique have an excellent result with no clinical or radiographic sign of suture anchors repair insufficiency.

Introduction: The objective of this study was to evaluate the structural properties of the native IOL and three different constructs for IOL reconstruction.

Methods: 24 fresh-frozen (FF) forearms, 6 FF Achilles (ACH) allografts, and 6 FF bone-patellar tendon-bone (BPTB) allografts were used. N=6 FCR, ACH, and BPTB reconstructions were performed at the angle of the native IOL. For the FCR and ACH constructs, 5 mm tunnels were drilled across the radius and ulna, the graft ends were sutured with a baseball stitch (#2 braided polyester), passed, cyclically pretensioned, and tied to suture posts under maximal manual tension. For the BPTB construct, troughs were created in the dorsal radius and ulna, and the bone blocks were secured in the troughs under maximal manual tension using 3.5 mm cortical lag screws.N=8 native IOL’s and N=6 each of the reconstruction constructs were resected from the forearms attached to 6 cm segments of radius and ulna.Specimens were potted and mounted on an Instron using custom clamps.

One-way ANOVA was used to compare results with p=0.05.

Results: The intact IOL was significantly 7–8 times stiffer than FCR/ACH and 3 times stiffer than BPTB constructs. Strength of the intact IOL was 3 to 4 times higher than FCR, ACH and BPTB constructs. No significant differences were detected between any properties of FCR and ACH grafts. BPTB displayed significantly greater structural properties compared to ACH and FCR.The load-elongation curves for the intact IOL displayed toe and linear regions, and abrupt failure typical for ligaments.

Discussion-conclusions:The graft constructs were structurally inferior to the native IOL. Achilles and FCR grafts were similar biomechanically, while BPTB displayed slightly higher properties. The BPTB reconstruction applied dorsally was observed to tighten in pronation, and become slack in supination, likely because these were dorsal to the interosseous ridge. It is important to note that all properties would be influenced by healing and remodeling in living subjects.

ACH and FCR reconstruction constructs were similar, but inferior to the intact IOL. BPTB was slack in supination. What remains unknown is how stiff an IOL reconstruction should be to provide a beneficial effect on forearm biomechanics. IOL reconstruction remains an experimental procedure.

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.

Massive rotator cuff tears associated with glenohumeral arthritis are currently an unsolvable clinical entity. This study strictly defines the use of bipolar hemiarthroptasty for the entity of RCTA.

Materials – Methods: We review our series of 14 patients with Rotator Cuff Tear Arthropathy (RCTA) who underwent a bipolar prosthesis of their shoulder. The average follow up was 27.8 months (range 24–48 months) and the average age was 71 years old (range 57–84 years old), of these 14 patients there were 9 male and 5 female. None of these patients had previous shoulder surgery and all patients underwent conservative treatment that failed to improve their symptoms or range of motion

Results: Preoperatively the average forward flexion was 300, external rotation 100 and the American Shoulder and Elbow Society (ASES) score was 25 points. Postoperativety the average forward flexion improved to 880, external rotation increased to 370 and the ASES score improved to 80 pts, 12 of the 14 patients stated that they had no pain with activities of daily living. Two patients persisted to have moderate pain in everyday activity.

Conclusion: We believe that bipolar hemiarthroplasty is currently a good option for treatment of Rotator Cuff Tear Arthropathy, The results of bipolar hemiarthroplasty provided more reliable pain relief than that for hemiarthroplasty.

Proximal Row Carpectomy (PRO has been used as an alternative treatment for advanced radiocarpal arthrosis and carpal collapse. Its use has been recommended for Kienbock’s disease, chronic scaphoid nonunion and scapholunate advanced collapse (SLAC) deformity.

Materials – Methods: Twenty-three patients were divided into two groups: group 1, consisting of patients with Kienbock’s disease (10 patients), and group 2, consisting of patients with scapholunate advanced collapse (13 patients). The average age was 51 years (range 27–69) for group 1, and 45 years (range 29–57) for group 2. The average follow-up was 30 months for Kienbock’s disease (range, 23–49 months) and 31 months for SLAC deformity of the wrist (range, 24–51 months). Pre-operative staging was performed on all patients utilizing Lichtmann’s (Lichtmann and Degnan, 1993) classification for Kienbock’s disease and Watson’s (Watson and Ballet, 1984) classification for scapholunate advanced collapse.

The procedure was performed as described by Jorgansen (1969) utilizing a dorsal midline approach between the third and fourth dorsal compartments. Styloidectomy, preserving the radiocapitate ligament was performed in 7 out of the 23 patients (5 Kienbock’s and 2 SLAC wrist’s patients). Posterior Interosseous Nerve neurectomy was performed in 2 out of the 10 patients with Kienbock’s disease. Results: Statistically significant differences were noted between the Kienbock’s disease group and the SLAC wrist group (p=0.0023). Of the patients who underwent PRC for Kienbock’s disease 9 of 10 patients reported moderate to severe pain at the final follow-up visits. In the scapholunate advanced collapse group, 2 out of 13 patients demonstrated moderate or severe pain. It was noted that the patients in the SLAC wrist group lost less motion overall than those in the Kienbock’s dis ease group (p=0.00l 5). It was noted in the Kienbock’s disease group that at final follow-up the operated hand was weaker than preoperative (p=0.022). In the scapholunate advanced collapse group there was improvement of postoperative grip strength.

Conclusion: We currently recommend the use of wrist arthroscopy as an adjunct to determine the status of the lunate articular surface in Kienbock’s disease, before performing a proximal row carpectomy. Our results indicate that despite only minor chondromalacia of the capitate articular surface and lunate facet of the radius, the use of PRC in Kienbock’s has not been rewarding.