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

Aims. The aim of this systematic review and meta-analysis is to evaluate differences in functional outcomes and complications between single- (SI) and double-incision (DI) techniques for the treatment of distal biceps tendon rupture. Methods. A comprehensive search on PubMed, MEDLINE, Scopus, and Cochrane Central databases was conducted to identify studies reporting comparative results of the SI versus the DI approach. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was used for search strategy. Of 606 titles, 13 studies met the inclusion criteria; methodological quality was assessed with the Newcastle-Ottawa scale. Random- and fixed-effects models were used to find differences in outcomes between the two surgical approaches. The range of motion (ROM) and the Disabilities of the Arm, Shoulder and Hand (DASH) scores, as well as neurological and non-neurological complications, were assessed. Results. A total of 2,622 patients were identified. No significant differences in DASH score were detected between the techniques. The SI approach showed significantly greater ROM in flexion (standardized mean difference (SMD) -0.508; 95% confidence interval (CI) -0.904 to -0.112) and pronation (SMD -0.325, 95% CI -0.637 to -0.012). The DI technique was associated with significantly less risk of lateral antebrachial cutaneous nerve damage (odds ratio (OR) 4.239, 95% CI 2.171 to 8.278), but no differences were found for other nerves evaluated. The SI group showed significantly fewer events of heterotopic ossification (OR 0.430, 95% CI 0.226 to 0.816) and a lower reoperation rate (OR 0.503, 95% CI 0.317 to 0.798). Conclusion. No significant differences in functional scores can be expected between the SI and DI approaches after distal biceps tendon repair. The SI approach showed greater flexion and pronation ROM and a lower risk of heterotopic ossification and reoperation. The DI approach was favourable in terms of lower risk of neurological complications. Cite this article: Bone Joint J 2020;102-B(12):1608–1617

We aimed to determine the distribution of the ABO and Rh blood groups in 832 patients with a tendon rupture. Among these, the frequency of blood group O (52.8%) was significantly higher than in the general population of Hungary (31.1%) and the frequency of group A was significantly lower. Of the 83 cases of multiple ruptures or re-rupture, 57 patients (68.7%) had group O blood. The dominance of group O was found for all sites of tendon rupture, but there was no significant association with the Rh groups. Individuals with blood group O appear to have an increased risk of tendon rupture

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

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

Purpose of Study: Once the decision is made to treat an acute Achilles tendon rupture by surgical procedure, the surgeon is confronted with numerous operative techniques. After Ma et al. have described the percutaneous suture, it exists a alternative to the open method. The ad- and disadvantages of both methods or of the conservative treatment are often discussed. It should be inverstigated how the results of operative treatment by percutaneous repair are and if there is a possibiltiy to improve them by the use of a modified technique. Method: The study includes 76 patients with Achillles tendon rupture, who underwent a percutaneous repair from 1999 to 2003 in our department. The patients were examined on average 26 months. In changing the original technique we used a straight needle for guiding the suture transversly through the wound. In addition the way how the neeedle is pushed into the tendon to adapt the stumps is modified. Results: All patients could be examined after the operation. The patients, who have done sports before the accident were able to return after the healing time. We saw no superficial or deep wound infection. We had 4 patients with sural nerve injuries, three resolved in six to nine months. There was one patient with a rerupture, who underwent open surgical repair. Conclusion: The percutaneous suture offers an interesting alternative method to the standard open repair in the treatment of Achilles tendon rupture

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

Aims

To determine whether the findings from a landmark Canadian trial assessing the optimal management of acute rupture of the Achilles tendon influenced the practice patterns of orthopaedic surgeons in Ontario, Canada.

Ochronosis, the musculoskeletal manifestation of alkaptonuria, is known to lead to degenerative changes of the spine and weight-bearing joints. Symptoms related to degeneration of tendons or ligaments with spontaneous ruptures have not previously been reported. Three patients are described with four spontaneous ruptures of either the patellar tendon or tendo Achillis as the first symptom of alkaptonuria.

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.

The imaging techniques available to aid the diagnosis of ruptures of tendo Achillis, the rotator cuff and the tendon of tibialis posterior in rheumatoid patients are well described. However, ruptures of tendon or muscle at other sites are uncommon and may be overlooked. Diagnosis is often made by localised tenderness, swelling and a lack of active movement associated with a palpable defect. Clinical examination may be inconclusive and can be aided by imaging studies. We report two cases in which ruptures of a tendon were suspected, and ultrasound imaging demonstrated the palpable defect to be a cleavage plane in the subcutaneous fat – a ‘fat fracture’

Objective: The aim of this study was to compare different patellar tendon repair constructs.

Materials and Methods: Eight pairs of cadaveric legs were used to compare metal suture anchor repair with “standard” Krakow tendon suture through patella bone tunnels and steel box wire augmentation loop repair. Each leg was retested with box wire augmentation loop and simple 2/0 polyglactin suture repair.

The repairs were tested by mounting the legs on a specially designed rig on a materials testing machine which allowed the leg to be cycled from 90° knee flexion to full extension. The specimens were cycled 1000 times at 0.25Hz or until the repair failed. Optical markers were attached to the leg which enabled the repair gap and knee angle to be monitored during testing (Smart Capture and Analyser Tracking system, Padua, Italy).

Results: Six out of eight suture anchor repairs failed, all suture bone tunnel repairs with augmentation loops completed 1000 cycles. One out of 16 augmentation loop with simple 2/0 suture repair failed.

For all specimens regardless of repair type that completed 1000 cycles there was no significant difference in repair gap distance.

Conclusion: Suture anchors alone do not provide a strong enough construct for patellar tendon repair.

The box wire augmentation loop is key to maintaining patellar tendon repair.

Krakow tendon sutures secured through patellar bone tunnels do not provide additional benefit to a simple appositional suture and box wire augmentation loop.

Rupture of the pectoralis major (PM) tendon is a rare yet severe injury. Several techniques have been described for PM fixation including a transosseus technique, when cortical buttons are placed at the superior, middle and inferior PM tendon insertion positions. The concern with this technique is the risk that bicortical drilling poses to the axillary nerve as it courses posteriorly to the humerus.

This cadaveric study investigates the proximity of the posterior branch of the axillary nerve to the drill positions for transosseus PM tendon repair. Drills were placed through the humerus at the superior, middle and inferior insertions of the PM tendon and the distance between these positions and the axillary nerve, which had previously been marked, was measured using computed tomography (CT) imaging.

This investigation demonstrates that the superior border of PM tendon insertion is the fixation position that poses the highest risk of damage to the axillary nerve.

Caution should be used when performing bicortical drilling during cortical button PM tendon repair, especially when drilling at the superior border of the PM insertion. We describe ‘safe’ and ‘danger’ zones for transosseus drilling of the humerus reflecting the risk posed to the axillary nerve.

Introduction

The healing of Achilles tendon rupture is slow and jogging is usually allowed already 6 months after injury. However, the metabolic status of the healing tendon is largely unknown at the time-points when increased loading is allowed. The purpose of this study was to investigate tendon metabolic response and blood flow at 3, 6 and 12 months after Achilles tendon rupture by positron emission tomography (PET) and ultrasound-Power Doppler (UPD).

Introduction. Acute distal biceps rupture can be a devastating injury and surgical repair offers the only real chance of full recovery. We report on a new surgical technique in which the use of suture anchors and a modified de-tensioning suture was employed to protect the repair in the early post operative recovery period and aid early rehabilitation and return to full pre-injury activity.

Materials & Methods. Using the standard anterior incision the distal biceps tendon was approximated to the radial tuberosity using two Mitek sutures and a sliding stitch. Using 2-0 Vicryl, de-tensioning sutures were used to attach the medial and lateral sides of the tendon to the underlying brachialis muscle. Post-operative recovery encouraged isometric contractions as early as 24 hours and after 2 weeks allowed flexion and extension with gravity eliminated. Six weeks onwards full active movement commenced with gradual increase in stretching and strengthening exercise.

Results. 14 patients underwent this procedure and all returned to pre-injury activity levels within 9 months. Follow up (6–14 months) demonstrated all had regained pre-injury levels of strength in flexion and supination.

Discussion. Using two suture anchors, it is suggested that load bearing strength is greater than the trans-osseous method, providing even tension is applied to both anchors. This can be achieved using a sliding stitch. De-tensioning sutures restore the isometric pull on biceps in the early phase and protects the repair.

Conclusion. All cases operated on in this way have made excellent recoveries and have returned to full pre-injury levels of activity. We therefore recommend this technique as a way of enhancing rehabilitation in what can be a devastating injury for the active sporting individual

Aims

To determine whether platelet-rich plasma (PRP) injection improves outcomes two years after acute Achilles tendon rupture.

To review the medium term results of acute repair of rupture of the biceps brachii insertion using a single incision bone anchor anatomical repair. Three patients with acute biceps brachii tendon insertion ruptures and treated surgically using a single incision bone anchor anatomical repair underwent dynamometer strength assessment of both arms using a KinCom isokinetic dynamometer. This was performed shortly after completion of rehabilitation (7–12 months after surgery) and again at 3.3 years after surgery. All patients were male (mean age 40.3 years, range 34 to 53). Surgery was performed less than 7 days post injury using the same technique. Isokinetic assessment was performed at a mean of 8.7 months post surgery (range 7 to 12 months) and again at assessment (maintained at medium term assessment). All patients had returned to their full premorbid occupation and level of sporting activity. Dynamometer results of a repaired dominant limb equated to approximately the strength of a normal non dominant limb, a repaired non dominant side equated to two thirds the strength of a normal dominant limb at early assessment. This relationship was maintained at the medium term assessment, however there was a substantial increase in strength in both affected and unaffected arms. The one incision approach, using bone anchors, is recommended as the method of choice providing an optimal surgical repair with a reduction in the risk factors theoretically associated with anatomical surgical repair. Our short-term results are comparable with other quantitative results published (for both bone anchor and non-bone anchor procedure). The medium term results how a measurable increase in strength of the repaired limb although the strength relative to the uninjured side remains the same as at early assessment

Objectives

Inflammation of the retrocalcaneal bursa (RB) is a common clinical problem, particularly in professional athletes. RB inflammation is often treated with corticosteroid injections however a number of reports suggest an increased risk of Achilles tendon (AT) rupture. The aim of this cadaveric study was to describe the anatomical connections of the RB and to investigate whether it is possible for fluid to move from the RB into AT tissue.