Diagnosis, Etiology and Outcomes of Revision Distal Biceps Tendon Reattachment.

PURPOSE: To evaluate the incidence, etiology, and clinical outcomes after revision distal biceps tendon repair. We hypothesized that re-ruptures are rare and can be reattached with satisfactory results. METHODS: Cases were identified from the case log of the senior author. Demographic information, details regarding the primary repair and subsequent injury, time between reinjury and reattachment, and operative findings were recorded. Clinical outcomes were assessed using the Disabilities of the Arm, Shoulder, and Hand (DASH) and American Shoulder and Elbow Surgeons-Elbow (ASES-E) functional outcome scoring systems. Range of motion, strength, and ability to return to work were recorded. RESULTS: We identified 10 patients with re-rupture, all of whom were men. Average age was 46 years (range, 35-57 years). Four ruptures occurred in the dominant arm. Three patients had a history of bilateral ruptures. Incidence of primary failure was 1.1%. In 6 patients, re-rupture occurred 6 days to 11 months after the primary surgery. Three patients described a sense of ripping or tearing after a specific traumatic event. Four others had persistent pain after the primary reattachment. Re-rupture resulted from the loss of fixation owing to technical error, the suture pulling out from the tendon, or suture breakage. Two patients required an allograft. The hook test was abnormal in 3 patients. Magnetic resonance imaging results did not affect the operative plan. Nine patients returned to their former occupation. Five returned for follow-up evaluation and completion of the DASH and ASES-E self-assessment examinations. Average DASH score was 4.4 (range, 0-19) and average ASES-E was 93.2 (range, 74-100). Postoperative average elbow flexion was 141° (range, 135° to 145°), elbow extension was -12° (range, -5° to -30°), pronation was 70°, and supination was 80°. Postoperative average supination strength was 87.8% of the nonsurgical arm (range, 79% to 106%); average pronation strength was 79.2% of the nonsurgical arm (range, 50% to 110%). CONCLUSIONS: Revision reattachment resulted in acceptable functional outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Inadvertent Harvest of the Median Nerve Instead of the Palmaris Longus Tendon.

BACKGROUND: The palmaris longus tendon is frequently used as a tendon graft or ligament replacement. In rare instances the median nerve has been inadvertently harvested instead of the palmaris longus for use as a tendon. METHODS: Nineteen cases in which the median nerve had been mistakenly harvested instead of the palmaris longus tendon were collected from members of the American Society for Surgery of the Hand (ASSH) Listserve. Surgeons involved in the subsequent care of the subject who had had an inadvertent harvest were contacted or the chart was reviewed. The reason for the initial procedure, the skill level of the primary surgeon, and when the inadvertent harvest was recognized were documented. When possible, the method of harvest and subsequent treatment were also documented. RESULTS: The most common initial procedure was a reconstruction of the elbow ulnar collateral ligament, followed by basal joint arthroplasty, tendon reconstruction, and reconstruction of the ulnar collateral ligament of the thumb metacarpophalangeal joint. Only 7 of the inadvertent harvests were recognized intraoperatively; in the remaining 12 cases the nerve was used as a tendon graft. The sensory loss was not recognized as being due to the inadvertent harvest until the first postoperative visit (2 subjects), 3 to 4 weeks (2 subjects), 2 to 3 months (2 subjects), 5 to 7 months (2 subjects), 1 year (1 subject), 3 years (1 subject), or 10 years (1 subject). Preoperative clinical identification of the presence or absence of a palmaris longus did not necessarily prevent an inadvertent harvest. CONCLUSIONS: Knowledge of the relevant anatomy is crucial to avoiding inadvertent harvest of the median nerve instead of the palmaris longus tendon.

Survival strategies in a changing practice environment.

A number of forces disrupt normal referral patterns to physicians, driving hospital consolidation, and changing the way medicine is practiced in the United States. Strategies have been implemented to keep services in-network and stem "leakage"-all in the name of population health management, reducing unit costs, and spreading financial risk among the insurers, hospitals, and physicians. To survive in the changing medical environment, independent unintegrated physicians need to consider different practice models. These models include accountable care organizations (ACOs), super groups, specialty networks, co-management agreements, professional service agreements (PSAs), and partnering with local hospitals. Each physician and physician group need to decide what works best for them and their geographical area. Physicians and physician groups may find that one or more of these models will improve their chance of economic survival.

Bilateral distal biceps tendon ruptures.

PURPOSE: To determine the incidence of bilateral distal biceps tendon ruptures. METHODS: A retrospective review of 321 patients who underwent operative repair of a distal biceps tendon rupture between 1988 and 2010 identified 26 patients with bilateral ruptures. We recorded patient age, mechanism of injury, time between symptom onset before the first surgery and subsequent contralateral symptoms, and time between surgeries. RESULTS: Twenty-two bilateral ruptures were confirmed intra-operatively, 3 by MRI, and 1 was lost to follow up. A total of 23 bilateral ruptures (92%) occurred in men. The average age at the initial rupture was 44 years (range, 29-74 y). The average age at subsequent rupture was 48 years (range, 36-79 y). Excluding the 2 women (age 72 and 79 y), the average age at the initial rupture was 42 years and the average age at subsequent rupture was 46 years. The average interval between ruptures was 4.1 years (range, 0.8-13.9 y). The initial rupture occurred in the dominant extremity in 12 cases (50%) and in the nondominant extremity in 10 cases (42%); in 3 patients (8%) the dominance was not documented or ambidextrous. Thirty-three percent were heavy laborers, 3 patients had a smoking history, and 1 patient reported a history of steroid use. Twenty-two patients (88%) had the second side repaired, where we noted that 12 (55%) of the second tendon ruptures were partial tears. CONCLUSIONS: The 8% cumulative incidence of bilateral biceps tendon ruptures in a consecutive series of biceps tendon repairs may be higher because not all patients were contacted, which introduced a sampling bias. This 8% rate is markedly higher than the reported rate of 1.2 per 100,000 for an isolated distal biceps tendon rupture. This implies that patients with a distal biceps tendon rupture are at risk for a rupture on the contralateral side. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic III.

Distal biceps tendon tears in women.

HYPOTHESIS: Is the presentation and outcome of surgical treatment of distal biceps tendon tears different in women than men? MATERIALS AND METHODS: From 1999 to 2008, 15 cases of distal biceps tendon tears in 13 female patients were treated surgically at a single institution. Mean age was 63 years (range, 48-79 years). A retrospective review evaluated patient presentation, diagnosis, and treatment. Postoperative outcomes were assessed by physical examination, a patient satisfaction survey, the American Shoulder and Elbow Surgeons (ASES) elbow assessment form, and the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. RESULTS: Two-thirds of the tears were in the dominant arm, of which 7 resulted from a single injury, and 8 reported insidious onset of symptoms. All patients presented with pain in the antecubital fossa. A distinct cystic mass was palpable in 6. Of the 15 cases, 13 were partially detached, 1 was completely detached, and 1 was weakly attached. Fourteen regained full strength, and all had nearly complete range of motion. Mean follow-up was 46 months (range, 2-117 months). Eleven completed a postoperative patient satisfaction survey, ASES elbow, and DASH questionnaire. Mean scores were 95 (range, 58-100) for ASES and 7 (range, 0-43) for DASH. The only complication was a transient lateral antebrachial cutaneous nerve sensory palsy. DISCUSSION: Distal biceps tendon tears in women present at an advanced age with no history of an acute injury. They are frequently associated with a cystic mass and have a predominance of partial tears. CONCLUSIONS: Distal biceps tendon tears in women present differently than in men. The tears are rarely complete and they respond well to surgical repair.

Effectiveness of magnetic resonance imaging in detecting partial and complete distal biceps tendon rupture.

PURPOSE: A magnetic resonance imaging (MRI) scan of the elbow is often obtained to confirm the clinical suspicion of a distal biceps tendon rupture. The goal of this study was to evaluate the effectiveness of MRI in diagnosing partial and complete distal biceps tendon ruptures as determined at the time of surgery. METHODS: We identified 22 partial and 24 complete distal biceps tendon ruptures operated on by a single surgeon. The preoperative MRIs of these patients were obtained, along with MRIs of the elbow in 10 asymptomatic individuals. Two musculoskeletal radiologists read each MRI without knowledge of the diagnosis or the surgical findings. Their interpretations were compared with the intraoperative findings and the results were statistically analyzed. RESULTS: The overall sensitivity and specificity of MRI were 92.4% and 100%, respectively, in detecting distal biceps tendon ruptures. The sensitivity and specificity of MRI for complete tears were 100% and 82.8%, respectively. The sensitivity and specificity of MRI for partial tears were 59.1% and 100%, respectively. CONCLUSIONS: Magnetic resonance imaging is an effective tool for diagnosing distal biceps tendon ruptures. Although MRI is extremely sensitive in diagnosing complete tears, it is substantially less sensitive in diagnosing partial tears. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.

Fragment-specific fixation of distal radius fractures using the Trimed device.

Fragment-specific fixation of the distal radius represents a new technique for addressing complex distal radius fractures. It signifies a substantial shift in the thought process of open reduction and internal fixation; each fracture fragment is addressed independently with small plates or wire forms, allowing comminuted fractures to be anatomically restored and early motion started. Although the system is at first daunting, its modularity provides flexibility for the surgeon to modify the fixation to the individual needs of the patient's specific fracture pattern and the surgeon's level of expertise. Once the technique has been learned, the surgeon will have in his or her armamentarium a powerful new tool to treat fractures that had before been difficult to address satisfactorily with conventional techniques.