All-suture anchor size and drill angle influence load to failure in a porcine model of subpectoral biceps tenodesis, a biomechanical study.

BACKGROUND: Tenodesis of the long head of the biceps tendon is frequently performed in shoulder surgery, and all-suture anchors have become more popular as fixation methods. However, uncertainty still exists regarding the ultimate load to failure of all-suture anchors and the best insertion angle at a cortical humeral insertion point. PURPOSE: The purpose of this study was to compare the biomechanical characteristics of three types of all-suture anchors frequently used for biceps tenodesis. In addition, the influence of two different insertion angles was observed in a porcine humeri model. METHODS: The ultimate load to failure and failure mode of three types of all-suture anchors (1.6 FiberTak®, 1.9 FiberTak®, 2.6 FiberTak®, Arthrex®) applicable for subpectoral biceps tenodesis were evaluated at 90° and 45° insertion angles in 12 fresh-frozen porcine humeri. The anchors were inserted equally alternated in a randomized manner at three different insertion sites along the bicipital groove, and the suture tapes were knotted around a rod for pullout testing. In total, 36 anchors were evaluated in a universal testing machine (Zwick & Roell). RESULTS: The 2.6 FiberTak® shows higher ultimate loads to failure with a 90° insertion angle (944.0 N ± 169.7 N; 537.0 N ± 308.8 N) compared to the 1.9 FiberTak® (677.8 N ± 57.7 N; 426.3 N ± 167.0 N, p-value: 0.0080) and 1.6 FiberTak® (733.0 N ± 67.6 N; 450.0 N ± 155.8 N, p-value: 0.0018). All anchor types show significantly higher ultimate loads to failure and smaller standard deviations at the 90° insertion angle than at the 45° insertion angle. The major failure mode was anchor pullout. Only the 2.6 FiberTak® anchors showed suture breakage as the major failure mode when placed with a 90° insertion angle. CONCLUSIONS: All three all-suture anchors are suitable fixation methods for subpectoral biceps tenodesis. Regarding our data, we recommend 90° as the optimum insertion angle. CLINICAL RELEVANCE: The influence of anchor size and insertion angle of an all-suture anchor should be known by the surgeon for optimizing ultimate loads to failure and for achieving a secure fixation.

Suture anchor fixation may be an alternative to tension band wiring in olecranon fractures: Finite element analysis.

OBJECTIVES: This study aims to analyze and compare total deformations with tension band wiring (TBW), intramedullary screw (IS) and novel suture anchor (SA) fixation methods, and to investigate practicality of SA fixation in olecranon fractures using finite element analysis (FEA). MATERIALS AND METHODS: This finite element analysis study was conducted between May 2019 and October 2019. TBW, IS and SA fixation methods were compared in order to analyze fracture behavior in the ulna and humerus using FEA, which is among the mathematical methods of stress analysis. Boundary conditions were applied to the created model and total deformation amounts were compared among the methods in terms of displacement. RESULTS: The lowest amount of displacement was obtained with TBW method (1.2095 mm), while IS method (2.7703 mm) showed the highest amount of total displacement. Total displacement was lower with SA system (2.0397 mm) compared to IS fixation. In addition, no problem was observed with SA system in terms of failure occurrence. CONCLUSION: According to the results of FEA, although the lowest amount of displacement was obtained with TBW, it is concluded that anchor fixation method may be an alternative with practicality and mechanical properties. However, further studies are needed to obtain more precise data.

A new intramedullary fixation method for distal biceps tendon ruptures: a biomechanical study.

BACKGROUND: Various techniques have been described for distal biceps tendon reinsertion. Although high success rates have been reported, all current techniques have specific shortcomings, with complications such as heterotopic ossification, nerve damage, and gap formation. The purpose of the present study was to biomechanically evaluate a new intramedullary fixation device that might reduce the risk of posterior interosseous nerve lesions. We therefore compared the fixation strength of this new intramedullary button with an extramedullary placed classic extracortical button. METHODS: A standard bicortical button was compared to the new intramedullary fixation device using fresh-frozen cadaveric specimens. The fixation strengths were tested both cyclically and statically. Load to failure and method of failure were also recorded. RESULTS: There were no failures during the cyclic load testing. The mean tendon-bone displacement was 0.87 ± 0.13 mm for the bicortical group and 0.83 ± 0.13 mm for the new button. During static loading, the mean load to failure for the bicortical group was 296 ± 97 N, whereas the new button group showed a higher mean load to failure of 356 ± 37 N. Breakout through the anterior cortex was recorded in 2 of 6 bicortically placed buttons and 1 of 6 in the new device. CONCLUSIONS: The new intramedullary fixation device yields comparable loads to failure compared with currently used techniques in a biomechanical setup. These findings together with the theoretical advantages suggest that this technique may be a valuable solution for the repair of distal biceps tendon rupture.

Using Interconnected Knotless Anchor for Suprapectoral Biceps Tenodesis Could Offer Improved Biomechanical Properties in a Cadaveric Model.

PURPOSE: To compare the biomechanical characteristics of the interconnected knotless anchor (IKA) fixation with the double knotless anchor (DKA) and interference screw (IS) fixation in the suprapectoral biceps tenodesis. METHODS: In total, 24 fresh-frozen human cadaveric shoulders (mean age, 67.3 ± 6 years) were used for the study. All the specimens were randomly divided into 3 experimental biceps tenodesis groups (n = 8): IKA, DKA, and IS. After tenodesis, each specimen was preloaded at 5 N for 2 minutes, followed by a cyclic loading test from 5 to 70 N for 500 load cycles. Finally, a destructive axial load to failure test (1 mm/s) was performed. All the values, including ultimate failure load, stiffness, cyclic displacement, and mode of failure were evaluated. RESULTS: The IKA provided the highest construct stiffness (38.9 ± 7.7 N/mm) and ultimate failure load (288.3 ± 47.6 N), the results for which were statistically better than the corresponding results in the IS and DKA groups. In terms of cyclic displacement, there were no statistical differences among the 3 fixation constructs. The most common failure mode was biceps tendon tearing in IS group (7/8) and IKA group (8/8). In the contrast, suture slippage accounted for the most common failure mode in DKA. CONCLUSIONS: In suprapectoral bicep tenodesis, IKA fixation appears to offer improved construct stiffness and ultimate failure load while maintaining comparable suture slippage as compared with IS fixation or DKA fixation in the current biomechanical study. CLINICAL RELEVANCE: The IKA fixation compares favorably with other techniques and could be an alternative clinical option for suprapectoral biceps tenodesis.

Suprapectoral biceps tenodesis with bicortical drilling procedures: anatomic analysis of chondral and axillary nerve risk with transhumeral pin guide.

BACKGROUND: Many biceps tenodesis (BT) procedures are described for treating proximal biceps pathology. Axillary nerve injury has been reported during BT using bicortical drilling techniques with variable results depending on the location. In addition, there is a risk of potential articular damage during suprapectoral BT. We sought to determine the distance between the axillary nerve and the posterior passage of a bicortical pin, as well as the risk of articular damage, and to analyze whether a lateral inclination of the pin could avoid the chondral risk during suprapectoral BT with bicortical drilling. METHODS: Ten cadaveric shoulders were divided into 2 groups. In the first group, we determined the axillary nerve distance from the posterior exit point of 3 pins in a suprapectoral position 15 mm distal to the humeral cartilage: perpendicular, 10° caudal, and 20° caudal inclination. We measured 2 distances from the pin: to the axillary nerve and to the cartilage border. In the second group, we set one pin at the same perpendicular position and set the second pin 15° laterally tilted to determine its extra-articular passage. RESULTS: No pin injured the nerve, whereas all pins showed a transchondral direction. The 20° caudal inclination was the nearest to the nerve (18.8 mm [95% confidence interval, 5.5-32 mm]), but the perpendicular position was the safer position (38.8 mm [95% confidence interval, 28-49.6 mm]). Tilting the pin direction 15° laterally prevented cartilage damage (P = .008). CONCLUSIONS: Suprapectoral BT with bicortical drilling performed 15 mm distal to the humeral cartilage is a safe procedure regarding the axillary nerve. A potential humeral chondral injury could be prevented with 15° of lateral inclination of the pin guide.

Open Biceps Tenodesis: A Biomechanical Comparison of 6 Fixation Techniques.

Tenodesis is used to treat pathology of the long head of the biceps tendon. The authors evaluated the biomechanical properties of 6 techniques for biceps tenodesis fixation. The authors dissected 42 fresh-frozen cadaveric shoulders (mean age, 71±9.8 years; 69% male specimens), leaving the proximal humerus, proximal biceps tendon, and pectoralis major insertion. Specimens were randomized to undergo biceps tenodesis with one of the following: (1) an interference screw; (2) a cortical button; (3) a double-loaded 2.9-mm polyetheretherketone anchor (DL-2.9); (4) a double-loaded 1.9-mm all-suture anchor (DL-1.9); (5) a single-loaded 1.7-mm all-suture anchor (SL-1.7); or (6) soft tissue tenodesis. Specimens then underwent load-to-failure axial traction testing. A generalized linear and latent mixed model with a random-effects term was used to account for specimen pairing. Mean failure loads ranged from 136 N (95% confidence interval, 103-169 N) in the cortical button group to 79 N (95% confidence interval, 58-99 N) in the interference screw group. Failure occurred most often when fixation sutures pulled out of the tendon; however, 7 specimens failed elsewhere. No significant differences in ultimate failure load were found by treatment group. The interference screw group showed significantly more weakness than the cortical button and DL-2.9 groups. Tendon quality and suture parameters are likely more important than the fixation technique in determining failure load. [Orthopedics. 2020;43(2):e102-e108.].

Biomechanical comparison of the three techniques for arthroscopic suprapectoral biceps tenodesis: implant-free intraosseous tendon fixation with Cobra Guide, interference screw and suture anchor.

PURPOSE: A new arthroscopic technique with Cobra Guide (CG) was developed to enable fast, controlled and strong intraosseous biceps tenodesis while avoiding an implant. The purpose of this study was to compare the newly developed suture-only biceps tenodesis technique [arthroscopic suprapectoral intraosseous implant-free biceps tenodesis (ASIIBT) with the new CG] to classical interference screws (IS) and suture anchors (SA) in terms of construct resistance to failure. MATERIALS AND METHODS: Fifty-eight human cadaveric shoulders were randomized into three treatment groups. Twenty shoulders received an IS, 19 SA and 19 ASIIBT. A biceps tenodesis was performed according to the techniques listed above. Cyclic loading tests on a dynamic loading testing device were used to measure and compare the resistance to failure pullout between the three groups. Hartley's Fmax test and Tukey's Honest Significant Difference method were used for statistical analysis. RESULTS: The construct with the greatest resistance was ASIIBT. Its resistance was statistically higher compared to the IS technique (p = 0.001). Resistance compared to the SA technique was not statistically significant (p = 0.123), although in seven cases ASIIBT resisted more than 50 cycles at 200 N, while the SA technique reached 50 cycles at 200 N in just two cases. During cyclic loading, each specimen failed at the tenodesis site. CONCLUSIONS: ASIIBT showed higher failure loads compared with IS and SA. Better construct performance of ASIIBT is due to greater absorption of distension forces which may improve final tenodesis healing. Also, the absence of an implant lowers additional costs and the chances for postoperative complications may be decreased significantly.

Arthroscopic tenodesis using a bioabsorbable interference screw and soft anchor: A case series of 60 patients.

BACKGROUND: Various arthroscopic tenodesis techniques for the treatment of long head of the biceps tendon pathologic abnormalities have been described. PURPOSE: This study evaluated the clinical outcomes of using a bioabsorbable interference screw and soft anchor for long head of the biceps tendon arthroscopic tenodesis. METHODS: Sixty patients treated by this technique between February 2013 and March 2015 were followed up for at least 2 years. In our operative technique, after the bone hole was made just proximal to the pectoralis major, the soft anchor was inserted at the bottom of the hole. After tenotomy of the long head of the biceps tendon proximal to the bone hole, the tendon was fixed into the bottom of the hole temporarily using the soft anchor. Finally, the tendon was fixed in the hole with a bioabsorbable interference screw. RESULTS: The UCLA score 15.1 points preoperatively and 32.4 points at follow-up (p < 0.05). The Constant 55.8 points preoperatively and 93.9 points at follow-up (p < 0.01). After biceps tenodesis, no cosmetic deformities were found in 56 patients (93.3%), and four patients (6.7%) had a Popeye deformity. On postoperative magnetic resonance evaluation, the long head of the biceps tendon was located on the bicipital groove without deviation in 53 cases (88.3%), on the bicipital groove with a partial deviation in 6 cases (10.0%), and outside the bicipital groove with complete deviation (dislocated) in 1 case (1.7%). CONCLUSION: We found that arthroscopic biceps tenodesis using a soft anchor provided a reliable means for treating biceps pathology with no cosmetic deformities and with good clinical results.

Novel implant-free loop Tenodesis vs. simple Tenotomy of the long biceps tendon - a biomechanical investigation.

BACKGROUND: Simple tenotomy and anchor tenodesis are commonly used in treatment of long biceps tendon (LHB) pathologies. The tenotomy can result in biceps distalization or cosmetic deformities. A novel loop Tenodesis Technique (LTD) could prevent a distalization of the biceps muscle without the risk of implant associated complications. The purpose of this study was to investigate the biomechanical aspects of the novel LTD compared to a standard tenotomy of the LHB. It has been hypothesized that the novel technique will show biomechanical superiority in terms of resistance and distalization. METHODS: Seven paired adult human cadaveric shoulder joints were assigned to one of the two study groups: Loop tenodesis (LTD); simple tenotomy (STT). In both groups load-to-failure testing was performed. The load-displacement curve was used to determine the maximum load (N), the degree of distalization of the LHB (mm) and the stiffness (N/mm). Additionally, the mode of failure was registered. RESULTS: The LTD group achieved a significantly higher ultimate load to failure (LTD: 50.5 ± 12.5 N vs. STT: 6.6 ± 3.9 N; p = 0.001). Significantly less distalization of the tendon could be detected for the LTD group (LTD: 8 ± 2.3 mm vs. STT: 22.4 ± 2.4 mm; p = 0.001). Stiffness was 7.4 ± 3.9 N/mm for the LTD group and 0.23 ± 0.16 N/mm for the STT group (p = 0.001). In all specimens of the LTD group a tendon rupture was found as mode of failure, while the STT group failed because of pulling out the LHB through the bicipital groove. CONCLUSION: The novel loop Tenodesis Technique shows biomechanically higher stability as well as less distalization compared to a simple tenotomy of the long biceps tendon.

Metallic versus biodegradable suture anchors for rotator cuff repair: a case control study.

BACKGROUNDS: Repair of full-thickness rotator cuff (RC) tears is routinely performed using suture anchors, which produce secure and effective soft tissue fixation to bone. The aim of this prospective study is to compare the long-term outcomes of single row arthroscopic rotator cuff repair (RCR) performed using metal or biodegradable suture anchors. The null hypothesis is that there is no difference in shoulder function using metal or biodegradable suture anchors as evaluated by UCLA shoulder score, Wolfgang criteria, and Oxford shoulder score. METHODS: Arthroscopic RCR was performed in 110 patients included in this case control study. They were divided into 2 groups of 51 and 59 patients respectively. Metal suture anchors were used in group 1, and biodegradable suture anchors in group 2. Results were obtained at a mean follow up of 4.05 + 2 years. Clinical outcomes and functional outcomes were evaluated. RESULTS: The mean modified UCLA shoulder score was 26.9 + 7.1 in group 1, and 27.7 + 6.5 in group 2 (P = 0.5); the mean Wolfgang score was 13.3 + 3.3 in group 1, and 14 + 2.6 in group 2 (P = 0.3); the mean OSS was 23.7 + 11.4 in group 1, and 20.7 + 9.2 points in group 2 (P = 0.1). The mean active anterior elevation was 163.5° + 28.2° in group 1 and 163.6° + 26.9 in group 2 (P = 0.9); the mean active external rotation was 46° + 19.7° in group 1 and 44.6° + 16.3° in group 2 (P = 0.7). The mean strength in anterior elevation was 4.8.02 + 23.52 N in group 1, and 43.12 + 17.64 N in group 2 (P = 0.2); the mean strength in external rotation was 48.02 + 22.54 N in group 1 and 46.06 + 17.64 N in group 2 (P = 0.6); the mean strength in internal rotation was 67.62 + 29.4 N in group 1, and 68.6 + 25.48 N in group 2 (P = 0.9). CONCLUSIONS: There are no statistically significant differences at a mean follow-up of 4.05 + 2 years in clinical and functional outcomes of single row arthroscopic RCR using metallic or biodegradable suture anchors for RC < 5 cm.

A Flexor Digitorum Superficialis Tenodesis Technique for Surgical Treatment of Finger PIP Joint Volar Plate Chronic Avulsion.

Background: Chronic, post-traumatic, avulsion of the proximal interphalangeal (PIP) joint volar plate represents a disabling lesion. The purpose of this report is to describe a flexor digitorum superficialis (FDS) tenodesis using a mini-bone anchor inserted into the proximal phalanx, and its clinical outcome. Methods: 15 patients with chronic post-traumatic hyperextension instability of the PIP joint were treated surgically. From the first post-operative day patients were invited to start an early gradual joint active motion, wearing an extension block splint. Forty days after surgery, clinical evaluations were carried out, including: joint stability, pain and range of motion (ROM). The use of a circumferential splint was recommended for two further months, avoiding strenuous manual activities. The range of motion, time lost at work and the functional results were recorded six months after surgery. Results: At last follow up, 7 of the 13 reviewed patients presented an excellent functional recovery, with complete resolution of pain and stability with attainment of ROM comparable to the contralateral finger. The others 6 patients obtained good results, with remission of the functional impairment and pain, with either residual hyperextension or flexion contracture. There was one case of recurrence consecutively to a premature traumatic work-related activity. Conclusions: The FDS tenodesis via a bone anchor, combined with early active PIP joint protected motion, was shown in this study to be effective and reliable.

Single-Bundle vs Double-Bundle (Anatomical) Reconstruction of the Thumb Ulnar Collateral Ligament: Biomechanical Study.

Background: The goal of this study is to compare the biomechanical properties of anatomic (double-bundle) versus single-bundle reconstruction of the thumb metacarpophalangeal (MCP) joint ulnar collateral ligament (UCL) in a cadaveric model. Methods: Twelve fresh frozen cadaver hands were randomly assigned to single- or double-bundle reconstruction groups using a palmaris longus autograft and tenodesis screws. Two blinded examiners performed mechanical testing and measurements using fluoroscopic imaging. We evaluated MCP joint congruence and angle in the coronal plane at 0°, 30°, and 60° of flexion with valgus loads of 1.36 and 2.72 kg. Maximum MCP flexion and extension with a 0.45 kg load was also measured. Results: There was no significant difference between single- versus double-bundle reconstruction in ulnar congruence or MCP angle. With varying amounts of flexion, there was no significant difference in MCP valgus angle between the 2 techniques, suggesting comparable joint congruity and coronal MCP angle along the arc of thumb MCP motion. Conclusions: Single- and double-bundle UCL reconstructions of the thumb MCP joint have comparable biomechanical properties in regard to joint congruity under valgus load.

Arthroscopic extra-articular suprapectoral biceps tenodesis with knotless suture anchor.

Tenodesis of the long head of the biceps tendon is a frequently performed procedure during shoulder arthroscopy. Various open and arthroscopic techniques have been described with comparable outcomes and complication rates. We describe a simple, knotless, arthroscopic extra-articular biceps tenodesis technique using a 4.5-mm knotless anchor. This technique avoids the complications associated with open tenodesis surgery while still removing the diseased biceps tendon from the bicipital groove. The benefits from knotless suture anchor include no requirement of arthroscopic knot tying and no risk of the knot irritation under the coracoid and coracoacromial ligament.

Complications of biceps tenodesis based on location, fixation, and indication: a review of 1526 shoulders.

BACKGROUND: Long head of the biceps tendon (LHBT) tenodesis is predominantly performed for 2 reasons: anterior shoulder pain (ASP) or structural reasons (partial tear, dislocation). METHODS: Between 2006 and 2014, all cases of primary LHBT tenodesis performed at an integrated health care system were retrospectively reviewed. Complications were analyzed by tenodesis location (below or out of the groove [OOG] vs leaving tendon in the groove [ITG]), fixation method (soft tissue vs implant), and indication (preoperative ASP vs structural). RESULTS: Among 1526 shoulders, persistent ASP did not differ by fixation method (11.0% for implant vs 12.8% for soft tissue, P = .550) or location (10.8% for OOG vs 12.9% for ITG, P = .472). Soft-tissue tenodesis cases had more frequent new-onset ASP (11.9% vs 2.6%, P < .001) and subjective weakness (8.50% vs 3.92%, P < .001) but less frequent revisions (0% vs 1.19%, P = .03) than implant tenodesis cases. No difference was found between ITG and OOG for persistent ASP (12.9% vs 10.8%, P = .550), new-onset ASP (6.5% vs 2.8%, P = .339), cramping (1.70% vs 2.31%, P = .737), deformity (4.72% vs 4.62%, P = .532), or subjective weakness (6.23% vs 4.32%, P = .334), but ITG cases had more revisions (1.51% vs 0.60%, P = .001). Among implant tenodesis cases, 1 shoulder (0.085%) sustained a fracture. CONCLUSION: The overall complication rate of LHBT tenodesis was low. Of the shoulders, 10.8% to 12.9% continued to have ASP, regardless of whether the LHBT was left ITG. Soft-tissue tenodesis cases had higher rates of new-onset ASP and subjective weakness. No significant difference for tenodesis ITG or OOG was found in biceps-related complications.

Is there a difference in clinical outcomes and repair integrity between arthroscopic single-row versus transosseous (anchorless) fixation? A retrospective comparative study.

BACKGROUND: Few studies have investigated clinical and structural outcomes after transosseous (TO) repair. The purpose of this study was to compare structural and clinical outcomes of rotator cuff tear, repaired arthroscopically, with a single row (SR) or transossoeus (TO) anchorless technique. METHODS: 96 patients who underwent an arthroscopic repair for superior or posterosuperior rotator cuff tear using TO (n:54) or a SR (n:42) were retrospectively enrolled in this study after evaluation of clinical and surgical notes. Functional evaluation was performed with the adjusted Constant score, and American Shoulder and Elbow Surgeons (ASES) score. Postoperative cuff integrity was determined through MRI study. RESULTS: Patients were recalled after a minimum follow-up of two years. All the patients were available for the study. In the SR group the Constant rating system showed a significant improvement from a preoperative average rating of 44.8 to an average of 85.7. In the group of TO repair the Constant rating system showed a significant improvement from a preoperative average of 46.1 to an average of 87.6 postoperatively. According to ASES index scores, the average total score improved from 42.8 to 92.0 in the anchor group and from 40.4 to 94.6 in the TO group. There was no statistical difference between the two groups about clinical outcomes. Postoperative MRI revealed no differences in term of complete re-tears between the two techniques. In the SR group at MRI we observe significant more cases of rotator cuff with a Sugaya type III healing. CONCLUSIONS: Arthroscopic rotator cuff repair yielded successful clinical outcomes using SR and TO technique. However using the TO technique we saw less type 3 Sugaya readings on MRI suggesting a possible benefit with TO repair. LEVEL OF EVIDENCE II: Retrospective study.

[Tear of the Distal Biceps Brachii Tendon - Correlation of Ultrasound and Operative Findings, Surgical Therapy Results]. / Ruptura distální slachy musculus biceps brachii ­ korelace sonografických a operacních nálezu, výsledky operacní terapie.

PURPOSE OF THE STUDY When treating tears of the distal biceps brachii muscle tendon, we repeatedly noticed a difference between the preoperative ultrasound findings and the operative findings. The aim of the study was to retrospectively correlate these findings in order to determine the sensitivity of the ultrasound examination in everyday orthopaedic practice. Moreover, we compared the results and complications of surgical treatment through two operative techniques used at our department. MATERIAL AND METHODS In the 2004-2016 period 20 patients underwent a surgery at our department for total tear of the distal tendon of the biceps brachii muscle. In 18 patients an ultrasound examination was performed preoperatively. In 3 patients it was repeated. Therefore, there were a total of 21 ultrasound observations made in this group of patients. Excluded were the cases of chronic tendinoses or inveterated tears. The group was divided into two sub-groups. The first sub-group was composed of patients in whom the preoperative ultrasound examination was performed by a radiologist-specialist in the musculoskeletal system, the second sub-group was composed of patients examined by a non-specialist. The ultrasound findings were compared with the operative findings. With the use of a formula for the calculation of sensitivity of the test, the sensitivity of the ultrasound examination was determined for proper recognition of a complete tear of the tendon concerned. Also, we compared the results and complications of the two operative methods applied: the technique using bone anchor vs. the Boyd-Anderson technique of transosseous reinsertion. RESULTS The sensitivity of the ultrasound examination was 91% in examinations performed by a radiologist-specialist and 40% in examinations performed by no-specialists. Both the surgical techniques brought very good results in our group of patients. The reported complications included 2 cases of temporary radial nerve palsy, 1 case of formation of heterotopic ossifications. DISCUSSION The sensitivity of ultrasound is adequate according to the literature. In our group of patients, the same applied only to examinations performed by a radiologist-specialist in the musculoskeletal system. This is because the ultrasound examination of the distal biceps tendon is a highly specialised examination. When performed by a non-specialist, the result of examination obtained in our observations is rather misleading, thus could lead to an improper method of treatment. Partial tears of this tendon are very rare according to the literature. Indirect signs of the partial tear presence at this location detected by ultrasound resulted in most cases in an incorrect diagnosis, therefore the description of a partial tear visualised by the ultrasound should be reserved exclusively for cases when intact fibrils are clearly detected during the examination. For unclear cases, the MRI scan is indicated. The results of both the surgical techniques of reinsertion applied were very good. The method using the bone anchors is technically easier to perform. Nonetheless, it has its specifics. CONCLUSIONS To diagnose correctly the tear of the distal biceps muscle tendon it is essential to perform a thorough clinical examination and to obtain the medical history of the patient, especially the mechanism of injury. Sonography can be beneficial only provided the examination is carried out by a specialist in the musculoskeletal system, with the use of appropriate device and under standard conditions. For surgical treatment of this injury we prefer the technique using a bone anchor, namely particularly since it is technically easier to perform. The functional results are very good. Key words: distal biceps tendon, elbow, tendon tear, ultrasound, suture anchors.

Use of cortical buttons for the fixation of the distal biceps tendon in combination with the double-incision technique-the relationship between the drill trajectory and the proximity to the posterior interosseous nerve: a cadaveric study.

BACKGROUND: The aim of this cadaveric study was to investigate different defined drill trajectories through the radial tuberosity for the placement of a cortical button and their proximity to the posterior interosseous nerve (PIN) by using the double-incision technique. METHODS: A total of 10 elbows from 5 fresh entire cadavers were used in this study. Detachment of the distal biceps tendon was performed to simulate its rupture. A standardized double-incision approach was performed, and the radial tuberosity was exposed in full pronation. A drill hole was applied perpendicular through the center of the tuberosity. Another 8 drill holes were applied with the same starting point at the tuberosity with defined trajectories. A cortical button was then placed through the center hole. The distances between the PIN and the exit holes of the different trajectories were measured. The cortical button was analyzed regarding muscle entrapment as well as its closest distance to the PIN. RESULTS: Contact of the PIN and the drill hole was observed for 6 of the 9 trajectories; only the proximal-ulnar, ulnar, and ulnar-distal trajectories had no contact with the PIN in any of the experiments. No contact of the cortical button and the PIN was observed for the ulnar and distal-ulnar drill trajectories only. The minimal distance to the PIN was 1.6 mm for both. CONCLUSION: Because of the potential risk of PIN injuries, the use of cortical button fixation in combination with the double-incision approach cannot be recommended.

Proximal row carpectomy, scaphoidectomy with midcarpal arthrodesis or midcarpal tenodesis: when and how to use.

I report my personal experience over three decades in the treatment of carpal collapse due to scapholunate collapse and scaphoid nonunion. I have used the proximal carpal row resection performed through palmar approach, the scaphoidectomy and double-column midcarpal arthrodesis, and scaphoidectomy with midcarpal tenodesis. Diagnostic arthroscopy is essential for staging and surgical decision making regarding the type of treatment. The details of the surgical techniques, tips, results and possible complications are described for each method. The advantage of the proximal row carpectomy by palmar approach is the early permitted rehabilitation with better recovery of wrist motility in comparison with the traditional technique. The advantage of the double-column midcarpal arthrodesis lies in its ease of execution. The midcarpal tenodesis is an excellent intervention from the conceptual point of view even if over time there is a progressive carpal collapse even in absence of symptoms.

Immediate physical therapy without postoperative restrictions following open subpectoral biceps tenodesis: low failure rates and improved outcomes at a minimum 2-year follow-up.

HYPOTHESIS: We aimed to determine patient-reported outcomes in patients undergoing open subpectoral biceps tenodesis with a dual-fixation construct who had no postoperative range-of-motion or weight-bearing restrictions. Our hypothesis was that patients without postoperative restrictions would have low failure rates with improved patient-reported outcomes. We further hypothesized that this technique would allow an earlier return to activity and similar functional outcomes when compared with those reported in the literature. METHODS: In this institutional review board-approved retrospective outcome study, we evaluated 105 patients who underwent primary open subpectoral biceps tenodesis with a bicortical suture button and interference screw construct without postoperative restrictions. The primary outcome measure was failure of the biceps tenodesis. Postoperative outcome scores included the Short Form 12 (SF-12) Physical Component Score; SF-12 Mental Component Score; American Shoulder and Elbow Surgeons total score and subscales; and Disabilities of the Arm, Shoulder and Hand score. RESULTS: A total of 98 patients (85%) were available for final follow-up at an average of 3.5 years. There were 2 failures (2.2%), at 5 weeks and 9 weeks postoperatively. Four patients underwent additional surgery unrelated to the previous tenodesis procedure. Final outcome scores indicated high levels of function, including the SF-12 Physical Component Score (mean, 51.5; SD, 7.8), SF-12 Mental Component Score (mean, 54.7; SD, 6.7), American Shoulder and Elbow Surgeons total score (mean, 89.4; SD, 14.2), and Disabilities of the Arm, Shoulder and Hand score (mean, 11.3; SD, 13.4). CONCLUSION: Open subpectoral biceps tenodesis using a dual-fixation construct with no postoperative motion restrictions resulted in excellent outcomes with a low incidence of failure.

Biomechanical properties of suprapectoral biceps tenodesis: double knotless screw fixation is superior to single knotless screw fixation.

INTRODUCTION: The purpose of this study is to biomechanically evaluate a new technique of double knotless screw fixation for suprapectoral biceps tenodesis and compare the results with that of the single knotless screw fixation as well as the interference screw fixation. METHODS: 24 fresh-frozen human cadaveric shoulders with a mean age of 68.3 ± 9 years were studied. The specimens were randomly divided into three experimental biceps tenodesis groups (n = 8): single knotless screw, double knotless screw and interference screw. Each tenodesis specimen was mounted on a mechanical testing machine, preloaded for 2 min at 5 N, tested with cyclic loading from 5 to 70 N for 500 load cycles and subjected to an axial load to failure test (1 mm/s). The ultimate failure load, stiffness, cyclic displacement and mode of failure were evaluated. RESULTS: The interference screw fixation had the highest ultimate failure load (215.8 ± 43.1 N) and stiffness (25.7 ± 5.2 N/mm) which were significantly higher than the corresponding results for the single and double knotless screw groups (P = 0.0029). The double knotless screw group had the second highest ultimate failure load (162.8 ± 13.8 N) and stiffness (15.1 ± 4.1 N/mm) which were significantly higher than the corresponding results for the single knotless screw technique (P = 0.0002). The most common mode of failure was suture slippage for both the double (7/8) and single knotless screw (6/8) groups while biceps tendon tearing occurred most often for the interference screw group (6/8). CONCLUSION: In this biomechanical study, the double knotless screw fixation was found to have a significantly greater ultimate failure load and stiffness than the single knotless screw fixation but lower values than the interference screw fixation.