Purpose of the study: Reinsertion of the brachial biceps on the radial tubercle has been an effective method for recovering cyclic supination. Several surgical techniques have been proposed but only one clinical evaluation of operated patients has been published. We report the first study of a clinical and magnetic resonance imaging (MRI) assessment of brachial biceps reinsertion in the anatomic position using an anchorage system. The purpose of this work ws to determine whether the reinserted biceps remains inserted and to analyze the zone of insertion.

Material and methods: Nine manual laborers underwent surgery between 1999 and 2003 for repair of a ruptured brachial biceps by reinsertion on an anchor. The patients were reviewed by an independent operator (measurement of force and flexion). A 3-Tesla MRI machine was used to evaluate the position of the reinserted biceps. Reinsertion was performed within 5 days of injury (range 3–9 days) using the same technique of anchorage in the radial tubercle in all cases. A longitudinal incision measuring 3–5 cm along the medial border of the radial brachial was made to localize the ruptured biceps and the radial tubercle and drill two or three insertion holes for the anchors. The suture threads were used to bring the brachial biceps tendon progressively to the anchor used as a pulley before knotting. The patients were immobilized for three weeks, limiting flexion to 0–90°, then 45–130° the three following weeks.

Results: For the nine patients, there were no cases of sepsis nor radioulnar synostosis. Three cases of calcification were noted and to cases of nervous complications which resolved totally. Six patients, mean age 44.8 years (range 34–54 years) (two patients had moved away from the region) were reviewed at mean 19.2 months (range 10–33 months). Force at maximum flexion was 94.6% of the opposite side (range 58–131.5%). Repeated supination was somewhat bothersome for two patients. None of the patients complained of work impairment and all resumed their activity at the same level within 4.6 months on average. The MRI analysis (available in five patients) demonstrated that the reinserted tendon was in contact with the bone and that ther was a visible bone-tendon junction: the anterior and posterior borders of the tendon, as well as the fivers, showed a regular configuration. The terminal part of the tendon was enlarged in 3/5 cases. The tendon signal from the last 3 cm was variable: low intensity signal on T1 and T2 sequences or discrete high intensity signal on T1 and T2. There was no evidence of peritendinous effusion. At the time of the MRI evaluation, the anchors had not been resorbed.

Discussion: Several studies have reported the usefulness of reinserting the branchial biceps in manual laborers. The half-approach techniques, especially by anchorage, avoid the double-approach, enabling less traumatic reinsertion. The branches of the radial nerve must be carefully identified (we observed only resolutive cases of nervous deficit). Nevertheless, this type of reinsertion has not been evaluated. There is no proof that the reinserted biceps remains in an anatomic position. Our MRI findings are in favor of continuing the single-strand suture technique since the evidence demonstrated the validity of this type of transosseous suture.

Purpose of the study: Locked centromedullary nailing has proven efficacy for the treament of tibial shaft fractures but its use remains controversial for the most distal fractures. The purpose of this work was to assess clinical and radiological outcome of nailing procedures used to treat fractures of the lower quarter of the leg.

Material and methods: Fifty-eight fractures of the lower quarter of the leg were treated by locked centromedul-lary nailing between 1999 and 2002. All patients were included in the analysis. Twenty-four patients aged 44 years on average (range 18–68 years) were reviewed by an independent operator at mean 43.2 months follow-up (range 18–70). Four types of nail were used, on an orthopedic table for 47 procedures and with a hanging leg for 11. The fibula was not fixed.

Results: Early complications were: compartment syndrome (n=2) and infection (n=3). Postoperative alignment was anatomic or good in 86%. Mean time to weight bearing was 66 days (range 0–180). Nonunion occurred in six patients who required revision. Secondary displacement was noted in ten patients. Knee motion was normal in all patients and ankle motion was normal in 80%. Mean time to resumed occupational activity was 5.7 months (range 1–18). At last follow-up, bone healing had been achieved in all patients.

Discussion: As compared with data in the literature, we found that locked centromedullary nailing allows early weight bearing with less risk of infection for radiological results comparable with those obtained with plate fixation. The secondary displacements resulted from defective locking of inappropriately adapted materials (holes insufficiently distal).

Conclusion: Locked centromedullary nailing is a treatment of choice for fractures of the distal quarter of the leg. Use of new nails with more distal holes should improve outcome by allowing distal locking with at least two screws in all cases.