Biceps tenotomy has earlier pain relief compared to biceps tenodesis: a randomized prospective study.

PURPOSE:  Surgical management for long head of the biceps (LHB) tendinopathy with either biceps tenotomy or tenodesis is a reliable, but debated treatment option. The aim of this prospective, randomized, single-blinded study is to evaluate differences in pain relief and subjective outcomes between biceps tenotomy versus tenodesis for LHB tendinopathy. METHODS:  Subjects were randomized and blinded to biceps tenotomy versus arthroscopic tenodesis intra-operatively. Outcomes evaluated included subjective patient outcome scores, pain, and cosmetic deformity. Subjective outcomes scores and pain were analyzed using a two-way ANOVA, controlling for concomitant rotator cuff repair. Binary outcomes were compared using Chi-square tests. RESULTS:  Thirty-four subjects (31 male, 3 female) with a median age of 56 (range 30-77) were enrolled. Twenty subjects were randomized to tenotomy and 14 to tenodesis. Fifty-six percent had concomitant rotator cuff repairs. The mean VAS pain score at 3 months was lower with tenotomy versus tenodesis. 2-year follow-up demonstrated no statistically significant differences for VAS, ASES, or SANE. 15/20 (75%) subjects with biceps tenotomy reported no pain medication use at the 2-week postoperative visit versus 5/14 (33%) for biceps tenodesis. Popeye deformity was found in 5/20 (25%) of tenotomy subjects versus 1/14 (7%) in tenodesis subjects. CONCLUSION: Outcomes appear similar between biceps tenotomy versus tenodesis; however, the tenotomy group demonstrated greater incidence of cosmetic deformity but an earlier improvement in postoperative pain. LEVEL OF EVIDENCE: Treatment Studies, Level II.

A knotless flexor tendon repair technique using a bidirectional barbed suture: an ex vivo comparison of three methods.

BACKGROUND: Flexor tendon repairs using conventional suture require knots that enlarge the cross-sectional area at the repair site. This enlargement increases the force of finger flexion and jeopardizes the integrity of a nascent tendon repair during rehabilitation. The authors hypothesized that a knotless flexor tendon repair using bidirectional barbed suture has similar strength and with reduced cross-sectional area compared with traditional techniques. METHODS: Sixty-six fresh porcine flexor digitorum profundus tendons were divided randomly into three groups. Tendons were transected and repaired with one of the following techniques: two-strand Kessler technique, four-strand Savage technique, or four-strand knotless technique. The cross-sectional area of each tendon was calculated at the repair site before and after repair. All tendons underwent mechanical testing to assess the 2-mm-gap formation force and ultimate strength. RESULTS: The 2-mm-gap formation force and ultimate strength of the Savage and knotless technique groups were not significantly different; however, both were significantly greater than those of the Kessler repair group (p<0.05). The repair-site cross-sectional area of tendons repaired with the knotless technique was significantly smaller than that of tendons repaired with the Kessler or Savage technique (p<0.01). Tendons repaired with the knotless technique also had a significantly smaller change in repair-site cross-sectional area (p<0.01). CONCLUSIONS: The authors demonstrate that knotless flexor tendon repair with barbed suture has equivalent strength and reduced repair-site cross-sectional area compared with traditional techniques. The smaller tendon profile may decrease gliding resistance, thus reducing the risk for postsurgical tendon rupture during rehabilitation.

Corrective osteotomy for isolated malunion of the palmar lunate facet in distal radius fractures.

PURPOSE: Malunion of the palmar lunate facet fragment of distal radius fractures is associated with both early functional impairment and late degenerative changes. The goal of this study was to describe the clinical and radiographic outcomes after corrective osteotomy for isolated malunion of the palmar lunate facet. METHODS: Between 1995 and 2000, a retrospective review identified 13 patients with an average age of 44 years who had undergone corrective intra-articular osteotomy for isolated malunion of the palmar lunate facet. The average interval from the initial injury to the osteotomy was 5.4 months. Final evaluation was performed at 1 year. We performed statistical analysis using the Wilcoxon signed rank test. RESULTS: Wrist extension improved from an average of 53° to 84° (p = .002), flexion from 46° to 61° (p < .002), supination from 38° to 87° (p = .002), and pronation from 79° to 87° (p < .001). Grip strength improved from 30% to 73% of the contralateral side (p < .002). Disabilities of the Arm, Shoulder, and Hand scores improved from an average of 50.7 to 9.7 (p < .002). Palmar tilt improved from an average of 23° to 11° (p < .002). Radial inclination improved from an average of 29° to 22° (p < .002), ulnar variance decreased from +3.9 to -0.9 mm (p = .004), and intra-articular gap decreased from 3.6 to 0.9 mm (p < .002). All patients had excellent or good results according to both the Gartland and Werley and the Fernandez scoring systems. CONCLUSIONS: Early intra-articular osteotomy significantly improved wrist range of motion, grip strength, Disabilities of the Arm, Shoulder, and Hand scores, and radiographic parameters. Patients reported mostly positive outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Management of subluxating ulnar nerve at the elbow.

Musculotendinous variations around the medial epicondyle can contribute to subluxation of the ulnar nerve at the elbow. This article reviews the presenting symptoms, operative findings, and results of surgery for subluxation of the ulnar nerve at the elbow. A retrospective evaluation was performed of 200 elbows managed operatively for medial elbow pathology over a 17-year period between 1990 and 2007. The patient charts were reviewed for chief complaint, radiographic studies, operative reports, and postoperative examination data. Seventeen patients (18 elbows) were treated for a subluxating ulnar nerve. Three patients were women and 14 were men, with a mean age of 27.6 years. Medial elbow pain was the chief complaint in all 17 patients. Seventeen elbows also demonstrated paresthesias in an ulnar nerve distribution. All patients were treated with anterior transposition of the ulnar nerve, and 11 patients (61%) were found to have a muscular anomaly. At a mean follow-up of 17 months, the mean visual analog scale for pain improved from 6.0 to 2.0. There was no functional impairment reported for any patient at final follow-up. Of the 200 elbows surgically treated for medial elbow pathology, 17 patients (8.5%) demonstrated a subluxating ulnar nerve. These patients tend to be young and present with a primary complaint of medial elbow pain. In addition, a subluxating ulnar nerve is often associated with muscular anomalies, which must be addressed concurrently.