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1.  Repair of acute and chronic distal biceps tendon ruptures using the EndoButton 
Hand (New York, N.Y.)  2010;6(1):39-46.
There are many ways to repair distal biceps tendon ruptures with no outcome studies demonstrating superiority of a specific technique. There are few studies reporting on the repair of acute and chronic distal biceps tendon ruptures using the EndoButton via an anterior single-incision approach. We report on 27 patients who underwent distal biceps tendon repair with an EndoButton. The average age was 50.1 years (range, 36–78). There were 17 acute repairs (within 4 weeks of injury), nine chronic repairs (greater than 4 weeks), and one revision of a previous acute repair. All chronic repairs were repaired without the need for graft augmentation. Patients were assessed postoperatively using the ASES elbow outcome instrument and isokinetic flexion and supination strength and endurance testing. Eight control subjects were also tested for comparison. At an average follow-up of 30.9 months, 26 of 27 patients returned to their previous employment and activity level. The average ASES elbow score was 98.2 (range, 81–100). Compared with the contralateral extremity, there was no loss of motion. Average flexion strength recovery was 101% and mean supination strength recovery was 99%. There was no significant difference in function or strength with repair of acute versus chronic ruptures. Using the EndoButton technique, acute and chronic distal biceps tendon ruptures can be repaired safely with excellent clinical results.
PMCID: PMC3041875  PMID: 22379436
Distal biceps tendon ruptures; Acute; Chronic; Single incision
2.  Is Therapy Necessary After Distal Biceps Tendon Repair? 
Hand (New York, N.Y.)  2008;3(4):316-319.
The EndoButton technique of distal biceps tendon repair provides strong biomechanical fixation. This strength of fixation may allow earlier postoperative range of motion (ROM). A retrospective review of 15 male patients undergoing single incision EndoButton repairs was used. Six subjects participated in conventional supervised postoperative rehabilitation while nine subjects were allowed unrestricted ROM after 2 weeks. Final ROM, time to full ROM, and Disabilities of Arm Shoulder and Hand (DASH) scores were compared. There was a significant difference for time to full ROM (p < 0.05). The mean time to full ROM was 8.67 weeks for the supervised therapy group and 4.38 weeks for the unrestricted group. There were no reruptures in either group. There were no significant differences in final ROM or DASH scores. These data suggest that unrestricted ROM results in a quicker return to full ROM without an increased risk of rerupture.
PMCID: PMC2584219  PMID: 18784965
Distal biceps tendon; EndoButton; Therapy; Tendon repair
3.  Distal biceps tendon rupture reconstruction using muscle-splitting double-incision approach 
AIM: To evaluate the clinical and functional results after repair of distal biceps tendon tears, following the Morrey’s modified double-incision approach.
METHODS: We retrospectively reviewed 47 patients with distal rupture of biceps brachii treated between 2003 and 2012 in our Orthopedic Department with muscle-splitting double-incision technique. Outcome measures included the Mayo elbow performance, the DASH questionnaire, patient’s satisfaction, elbow and forearm motion, grip strength and complications occurrence.
RESULTS: At an average 18 mo follow-up (range, 7 mo-10 years) the average Mayo elbow performance and DASH score were respectively 97.2 and 4.8. The elbow flexion range was 94%, extension was -2°, supination was 93% and pronation 96% compared with the uninjured limb. The mean grip strength, expressed as percentage of respective contralateral limb, was 83%. The average patient satisfaction rating on a Likert scale (from 0 to 10) was 9.4. The following complications were observed: 3 cases of heterotopic ossification (6.4%), one (2.1%) re-rupture of the tendon at the site of reattachment and 2 cases (4.3%) of posterior interosseous nerve palsy. No complication required further surgical treatment.
CONCLUSION: This technique allows an anatomic reattachment of distal biceps tendon at the radial tuberosity providing full functional recovery with low complication rate.
PMCID: PMC4133426  PMID: 25133147
Distal biceps tendon; Rupture; Double incision; Complications; Clinical outcome; Trans-osseous tunnels; Morrey
4.  Simultaneous bilateral distal biceps tendon ruptures repaired using an endobutton technique: a case report 
The simultaneous rupture of both distal biceps tendons is a rare clinical entity that is difficult to treat and can have poor outcomes. A variety of treatment and rehabilitation options exist and have been reported for single sided and staged bilateral repairs, but none have described an approach for acute bilateral ruptures. Repairing distal biceps tendon ruptures using a single anterior incision and a cortical suspensory button technique has become increasingly popular in recent years. We present a report of our surgical approach using an endobutton technique and rehabilitation algorithm for this unusual injury pattern.
Case presentation
A 43-year-old Caucasian man presented with acute onset bilateral elbow pain while lifting a large sheet of drywall off the ground. He initially felt a ‘pop’ on the right and almost immediately felt another on the left after having to quickly shift the weight. He was unable to continue working and sought medical attention. His pain was predominantly in his bilateral antecubital fossae and he had significant swelling and ecchymoses. His clinical examination demonstrated no palpable tendon, a retracted biceps muscle belly, and clear supination weakness. Magnetic resonance imaging was performed and showed bilateral distal biceps tendon ruptures with retraction on both sides. After discussion with our patient, we decided that both sides would be repaired using a single anterior incision with endobutton fixation, first his right followed by his left six weeks later.
Overall, our patient did very well and had returned to full manual work by our last follow-up at 30 months. Although he was never able to return to competitive recreational hockey and was left with mild lateral antebrachial cutaneous nerve dysesthesias on his right, he felt he was at 85% of his premorbid level of function. We describe what we believe to be, to the best of our knowledge, the first case of simultaneous bilateral distal biceps tendon ruptures successfully treated with a single-incision endobutton technique, which represents a valid option in managing this difficult problem.
PMCID: PMC3766066  PMID: 23972255
5.  Clinical results of a surgical technique using endobuttons for complete tendon tear of pectoralis major muscle: report of five cases 
We herein describe a surgical technique for the repair of complete tear of the pectoralis major (PM) tendon using endobuttons to strengthen initial fixation.
Five male patients (3 judo players, 1 martial arts player, and 1 body builder) were treated within 2 weeks of sustaining complete tear of the PM tendon. Average age at surgery and follow-up period were 28.4 years (range, 23-33) and 28.8 months (range, 24-36). A rectangular bone trough (about 1 × 4 cm) was created on the humerus at the insertion of the distal PM tendon. The tendon stump was introduced into this trough, and fixed to the reverse side of the humeral cortex using endobuttons and non-absorbable suture. Clinical assessment of re-tear was examined by MRI. Shoulder range of motion (ROM), outcome of treatment, and isometric power were measured at final follow-up.
There were no clinical re-tears, and MRI findings also showed continuity of the PM tendon in all cases at final follow-up. Average ROM did not differ significantly between the affected and unaffected shoulders. The clinical outcomes at final follow-up were excellent (4/5 cases) or good (1/5). In addition, postoperative isometric power in horizontal flexion of the affected shoulder showed complete recovery when compared with the unaffected side.
Satisfactory outcomes could be obtained when surgery using the endobutton technique was performed within 2 weeks after complete tear of the PM tendon. Therefore, our new technique appears promising as a useful method to treat complete tear of the PM tendon.
PMCID: PMC3199274  PMID: 21955511
6.  Fixation of Acute Distal Biceps Tendon Ruptures Using Mitek Anchors: A Retrospective Study 
Purpose of this Study:
The aim of this study was to evaluate the outcomes of surgical intra-osseous fixation of the distal tendon of the ruptured biceps brachii muscle using Mitek anchors.
Materials and Methods:
Between 2005 and 2011, seven patients underwent unilateral distal biceps tendon repair using Mitek anchors. All patients were men aged between 36 and 47 years. Six patients were assessed by physical examination and use of the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire.
Surgery was performed within 3 to 17 days of rupture with a mean follow-up of 35 months. Of the six fully completed DASH questionnaires, three patients had a score of 0, and three patients had scores of 5.8, 10 and 10.8, respectively (10.1 is the mean score for the general population). Transient paraesthesias in the lateral antebrachial cutaneous nerve region occurred in two patients and one patient experienced a transient stiffness of the elbow due to scarring of the wound. No major complicatons have occurred.
The use of Mitek anchors for the re-insertion of the ruptured distal biceps tendon proved to be a safe and effective technique with excellent functional results in our series.
PMCID: PMC3988494  PMID: 24741379
Bone anchors; DASH score; distal biceps tendon ruptures; Mitek anchors; single incision technique; surgical treatment.
7.  Distal Biceps Tendon Repair: An Analysis of Timing of Surgery on Outcomes 
Journal of Athletic Training  2013;48(1):9-11.
Surgical repair of the ruptured distal biceps brachaii tendon is an effective treatment in injured patients. Timing of surgery is considered an important factor when managing these patients.
To compare our outcomes after distal biceps tendon acute (at 4 weeks or less) or chronic (greater than 4 weeks) repair.
Cohort study.
Clinical practice.
Patients or Other Participants
Of 18 patients in a tertiary practice who underwent distal biceps repair, 12 and 6 underwent acute or chronic repair, respectively. The average durations from injury to surgery were 15.3 (range, 9 to 25) and 50.1 (range, 29 to 75) days for the acute and chronic groups, respectively.
Distal biceps tendon repair.
Main Outcome Measure(s)
Disabilities of the Arm, Shoulder and Hand (DASH) scoring, range of motion, and clinical and radiographic complications.
No differences were noted between the groups in DASH scoring or range of motion. No complications occurred, and radiographic outcomes were satisfactory, without evidence of heterotopic ossification in any patients.
Secure repair of a distal biceps tendon injury may yield similar results, whether it is performed in the acute or chronic setting.
PMCID: PMC3554038  PMID: 23672320
upper extremity; elbow; DASH; outcomes; chronicity
8.  Anatomical evaluation of a cortical button for distal biceps tendon repairs 
Hand (New York, N.Y.)  2013;8(2):201-204.
The posterior interosseous nerve (PIN) is at risk for injury during one-incision distal biceps tendon repair using a cortical button. The purpose of this study was to evaluate the proximity of a cortical button to the PIN during one-incision repairs of the distal biceps tendon using human cadaveric models.
In ten cadaveric elbows the biceps tendon was identified, traced to its insertion, and transected. With the forearm supinated, a guide pin was drilled through the radial tuberosity at a 0°, perpendicular to the table. A dorsal incision was used to identify the PIN. The tendon was repaired with a cortical button, ensuring the device lay in line with the radial shaft. The distance from the device to the PIN was measured using digital calipers. This process was repeated with the guide pin aimed at 20° proximal toward the radiocapitellar joint (RCJ) and 30° distal toward the wrist. The data were compared using a Student’s paired t-test.
The average distance from the device to the PIN with the straight posterior insertion was 8.94 mm, 11.86 mm with 20° proximal, and 0.55 mm with 30° distal angles. The distance between the button and the PIN was significantly greater when aiming the device 20° toward the RCJ compared to the straight insertion technique (p = 0.0061).
The distance between the PIN and cortical button can be significantly increased by aiming the guide pin between 0° and 20° proximal toward the RCJ and placing the device in line with the radial shaft.
PMCID: PMC3652991  PMID: 24426919
Distal biceps; Anatomical study; Elbow surgery; Tendon repair; Posterior interosseous nerve
9.  Reconstruction of Posterior Interosseous Nerve Injury Following Biceps Tendon Repair: Case Report and Cadaveric Study 
Hand (New York, N.Y.)  2008;4(2):134-139.
Surgical repair of distal biceps tendon rupture is a technically challenging procedure that has the potential for devastating and permanently disabling complications. We report two cases of posterior interosseous nerve (PIN) injury following successful biceps tendon repair utilizing both the single-incision and two-incision approaches. We also describe our technique of posterior interosseous nerve repair using a medial antebrachial cutaneous nerve graft (MABC) and a new approach to the terminal branches of the posterior interosseous nerve that makes this reconstruction possible. Finally, we advocate consideration for identification of the posterior interosseous nerve prior to reattachment of the biceps tendon to the radial tuberosity.
PMCID: PMC2686781  PMID: 18855074
Posterior interosseous nerve; Biceps tendon repair; Nerve graft; Nerve reconstruction; Radial nerve
10.  Management of acute displaced midshaft clavicular fractures using Herbert cannulated screw: Technique and results in 114 patients 
A new and simple operative technique has been developed to provide internal fixation for midshaft clavicle fractures. This involves the use of a large fragment Herbert Screw that is entirely embedded within the bone. Screw fixation is combined with bone grafting from intramedullary reamings of the fracture fragments. The purpose of this report is to assess the outcomes following treatment of midshaft clavicular fracture using this method.
Materials and Methods:
One hundred and fourteen patients with acute displaced midshaft fracture were identified between 2002 and 2007. All patients were followed until fracture union. Patients’ medical records were reviewed. Disability of the Arm, Shoulder, and Hand questionnaire (DASH), and American Shoulder and Elbow Surgeons Elbow form (ASES) were posted to all patients. Outcome measures included union rate, time to union, implant removal rate, DASH, and ASES scores.
Patients’ median age was 29.5 years (interquartile range, 19-44 years). The most common injury mechanism was sports injury (28%). The median time from injury to surgery was 5 days (interquartile range, 2-9 days). Union occurred in an average of 8.8 weeks. Non-union occurred in three cases (2.6%). The re-operation rate for symptomatic hardware prominence screw was 1.7%. The median DASH score was 0.83 and the median ASES was 100 (n = 35).
Intramedullary fixation using cannulated Herbert screw can be used as an effective approach for operative management of midshaft clavicular fractures. Using this method, an appropriate outcome could be achieved and a second intervention for implant removal could be avoided in great majority of cases.
Level of Evidence:
Level III
PMCID: PMC3743031  PMID: 23960363
Acute fracture; Herbert cannulated screw; internal fixation; intramedullary; midshaft clavicle fractures; open reduction
11.  Rupture of the Distal Biceps Tendon Combined with a Supinator Muscle Tear in a 51-Year-Old Woman: A Case Report 
Case Reports in Radiology  2011;2011:515912.
Distal biceps tendon rupture is a relatively uncommon occurrence in the general female population, and to our knowledge, has not been reported in association with a supinator muscle tear. We report a case of 51-year-old woman who experienced sharp pain in her forearm and elbow after lifting a heavy object. History and physical examination raised suspicion for a distal biceps tendon rupture. MRI imaging determined a combined distal biceps tendon tear with a supinator muscle tear with subsequent confirmation at surgery. Surgical repair was performed for the distal biceps tendon only through a single incision approach using the Endobutton technique.
PMCID: PMC3350064  PMID: 22606548
12.  Pin and plate fixation in complex distal humerus fractures: surgical technique and results 
International Orthopaedics  2011;36(4):839-844.
Complex distal humerus fractures are difficult to fix by conventional methods, especially in comminuted low distal humerus fractures. We propose a technique using small diameter K-wires and a plate on the humeral shaft.
Between May 2007 and March 2009, 19 patients with poor bone quality showing comminuted or low distal humerus fractures involving the articular surface were referred to our institution and were primarily treated by this technique that we called “pin and plate fixation”. We have reviewed all the cases treated by this method.
The average age was 46 years. All of the patients were followed up for a mean of 12 months and had a good range of motion (the average total arc of flexion-extension was 99°); the average Disabilities of the Arm, Shoulder and Hand (DASH) score was 18 points. The Mayo Elbow Performance Index was measured and the mean score was 88 in our patients.
In this study, a technique has been evaluated for the treatment of complex distal humerus fractures. We recommend this technique in comminuted, osteoporotic or low distal humerus fractures in which other fixation methods seem difficult or even impossible.
PMCID: PMC3311817  PMID: 21881883
13.  Complications after subpectoral biceps tenodesis using a dual suture anchor technique 
A variety of fixation techniques for subpectoral biceps tenodeses have been described including interference screw and suture anchor fixation. Biomechanical data suggests that dual suture anchor fixation has equivalent strength compared to interference screw fixation. The purpose of the study is to determine the early complication rate after subpectoral biceps tenodesis utilizing a dual suture anchor technique.
Materials and Methods:
A total of 103 open subpectoral biceps tenodeses were performed over a 3-year period using a dual suture anchor technique. There were 72 male and 31 female shoulders. The average age at the time of tenodesis was 45.5 years. 41 patients had a minimum of 6 months clinical follow-up (range, 6 to 45 months). The tenodesis was performed for biceps tendonitis, superior labral tears, biceps tendon subluxation, biceps tendon partial tears, and revisions of prior tenodeses.
There were a total of 7 complications (7%) in the entire group. There were 4 superficial wound infections (4%). There were 2 temporary nerve palsies (2%) resulting from the interscalene block. One patient had persistent numbness of the ear and a second patient had a temporary phrenic nerve palsy resulting in respiratory dysfunction and hospital admission. One patient developed a pulmonary embolism requiring hospital admission and anticoagulation. There were no hematomas, wound dehiscences, peripheral nerve injuries, or ruptures. In the sub-group of patients with a minimum of 6 months clinical follow-up, the only complication was a single wound infection treated with oral antibiotics.
Subpectoral biceps tenodesis utilizing a dual suture anchor technique has a low early complication rate with no ruptures or deep infections. The complication rate is comparable to those previously reported for interference screw subpectoral tenodesis and should be considered as a reasonable alternative to interference screw fixation.
Level of Evidence:
Level IV-Retrospective Case Series
PMCID: PMC4124673  PMID: 25114415
Biceps; complications; subpectoral; tenodesis Key Message: Subpectoral biceps tenodesis utilizing a dual suture anchor technique provides a low early complication rate comparable to previously reported rates for interference screw fixation. These early clinical findings are consistent with biomechanical data supporting that a dual suture anchor subpectoral technique has equivalent initial biomechanical strength compared to an interference screw.
14.  The Biceps Crease Interval for Diagnosing Complete Distal Biceps Tendon Ruptures 
Complete distal biceps tendon ruptures require prompt surgical management for optimal functional and aesthetic outcome. The need exists for a valid and reliable diagnostic tool to expedite surgical referral. We hypothesized complete distal biceps tendon ruptures result in an objectively measurable anatomic landmark (the distance between the antecubital crease of the elbow and the cusp of distal descent of the biceps muscle, or the biceps crease interval), as a result of proximal retraction of the musculotendinous complex. We established normal biceps crease interval values and biceps crease ratios between dominant and nondominant arms in 80 men with no history of biceps injury (average age, 43 years). The mean (± standard deviation) biceps crease interval for dominant and nondominant arms was 4.8 ± 0.6 cm. The mean biceps crease ratio was 1.0 ± 0.1. We measured the biceps crease interval and biceps crease ratio on 29 consecutive patients presenting with a possible complete distal biceps tendon rupture. Using a diagnostic threshold of a biceps crease interval greater than 6.0 cm or biceps crease ratio greater than 1.2, the biceps crease interval test had a sensitivity of 96% and a diagnostic accuracy of 93% for identifying complete distal biceps tendon ruptures, making it a valid and reliable tool for clinicians to identify cases requiring urgent surgical referral.
Level of Evidence: Level II, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.
PMCID: PMC2492996  PMID: 18551349
15.  Clinical Outcomes After Posterior Open Elbow Arthrolysis for Posttraumatic Elbow Stiffness 
Archives of Trauma Research  2014;3(3):e21742.
Loss of motion is a well-known complication after elbow trauma and in severe cases, arthrolysis of elbow is the procedure of choice. The posterior approach might have some advantages especially in post-traumatic patients who have undergone the same surgical approach in the past.
The aim of this study was to evaluate the short-term outcomes of elbow arthrolysis through posterior approach. Moreover, we assessed the effect of operation on the patients’ quality of life.
Patients and Methods:
During a retrospective-cohort study, the medical records of 14 patients (12 men, two women) whose range of movement had been limited post-traumatically and had undergone elbow arthrolysis with posterior approach were reviewed. Before intervention, the patients had a flexion less than 100 degrees or an extension lag of 30 degrees or more. For evaluation of the final outcomes, they were invited to participate in our study and the final range of motion, visual analogue score (VAS), disability of arm, shoulder and hand (DASH), Mayo elbow score (MES) and short form health survey (SF-36) scores were measured in the patients.
Mean age of the participants was 28.7 years. The interval from initial injury and arthrolysis was 16 months and the patients were followed for 14 months. The mean range of motion in patients before surgery was 35.8 degrees, which was increased to a mean of 108.9 after the surgery, indicating a 73.1 degrees improvement. The means of VAS, DASH, Mayo elbow and SF-36 scores in the patients were 1.6, 34, 68 and 43, respectively. A significant inverse correlation was found between the preoperative range of motion and final range of motion.
According to our results, elbow arthrolysis through posterior approach could be an effective technique with low complications. Since the final range of motion improved significantly, it might be a valuable method in promoting the patients’ quality of life.
PMCID: PMC4276709  PMID: 25599069
Elbow; Stiffness; Release; DASH
16.  Arthroscopy-assisted reconstruction of coracoclavicular ligament by Endobutton fixation for treatment of acromioclavicular joint dislocation 
The aim of this study was to evaluate the clinical outcomes of arthroscopy-assisted reconstruction of the coracoclavicular (CC) ligament using Endobutton for treating acromioclavicular (AC) joint dislocation.
From March 2012 to May 2013, a total of 22 patients with fresh AC joint dislocation (Rockwood type III and type V) were treated with arthroscopy-assisted Endobutton reconstruction of the CC ligament. The regular post-operation follow-up was performed. Shoulder joint function was assessed with Constant–Murley scores. Postoperative efficacy of the surgery was evaluated using the Karlsson criterion.
The 22 patients were followed postoperatively for an average of 24 months (16–31 months). Among them, 20 patients achieved good functional recovery with no pain. Two patients had slight pain in the acromion during shoulder joint motion with limited abduction at 3 months, both of whom had recovered at 6 months. Radiography confirmed anatomical reduction of the AC joint in all patients. At 1 year, the Constant–Murley scores were 93.1 ± 2.4 points on the injured side versus 94.2 ± 2.7 points on the uninjured side. The difference did not reach statistical significance (P > 0.05). Postoperative Karlsson evaluation ranked 20 patients (90.9 %) as grade A and 2 as grade B (9.1 %) at the 3-month follow-up. All patients had become grade A at 6 months. None of the patients had brachial plexus or peripheral vascular injuries.
Arthroscopy-assisted reconstruction of the coracoclavicular ligament by Endobutton fixation is a safe, easy method for treating AC joint dislocation. It provides reliable fixation, causes little trauma, and has a fast recovery.
PMCID: PMC4281352  PMID: 25421528
Arthroscopy; Endobutton; Coracoclavicular ligament; Acromioclavicular dislocation; Ligament repair
17.  Where to Tenodese the Biceps: Proximal or Distal? 
The best location for biceps tenodesis is controversial as surgeons have begun to question whether tenodesis location affects the incidence of residual bicipital postoperative pain. An open distal tenodesis technique has been previously proposed to eliminate remaining symptoms at the bicipital groove.
We asked the following questions: (1) Does a higher tenodesis in the biceps groove result in postoperative pain? And (2) can the tenodesis location be successfully moved more distally (“suprapectoral tenodesis”) by an arthroscopic technique?
We retrospectively reviewed 17 patients undergoing arthroscopic biceps tenodesis and evaluated their tenodesis location, either within the upper half of the groove (five) or in the lower half of the groove or shaft (12). Patient outcomes were assessed with visual analog scale scores for pain, American Shoulder and Elbow Surgeons scores, and Constant-Murley scores. Minimum followup was 12 months (mean, 28 months; range, 12–69 months).
Two patients had persistent pain at 12 months; both had a tenodesis in the upper half of the groove. The overall American Shoulder and Elbow Surgeons and Constant-Murley scores were improved at latest followup.
Arthroscopic suprapectoral biceps tenodesis represents a new technique for distal tenodesis. Our preliminary observations suggest a more distal tenodesis location may decrease the incidence of persistent postoperative pain at the bicipital groove, although additional research is needed to definitively state whether the proximal location is in fact more painful.
Level of Evidence
Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
PMCID: PMC3048262  PMID: 21107924
18.  A Simple Grafting Method to Repair Irreparable Distal Biceps Tendon 
Irreparable distal biceps tendon tears typically are treated using a free tendon graft. We asked whether our new method to fix the graft—using two suture anchors—yields similar results to our previous bone canal method. We compared the two methods for strength, endurance, and clinical findings. There were two groups, the suture anchor group (Group A, seven patients) and the bone canal group operated on before suture anchors (Group B, seven patients). The patients were males with a mean age at surgery of 44.9 years. The operative delay from primary trauma to index surgery averaged 5.9 months. The minimum followup was 2 years (mean, 11.1 years; range, 2–23 years). The mean arc of elbow motion was 0° to 132°, pronation 83°, and supination 80°. Compared with the contralateral side, the maximal peak torque was 84% in supination and 91% in pronation, and the maximal static elbow flexion strength was 94%. The Mayo elbow score averaged 99 in Group A and 100 in Group B. There were no major differences between the two groups. Our novel modification to fix a tendon graft yields equal clinical outcomes compared with the bone canal method for treatment of irreparable distal biceps tendon injuries.
Level of Evidence: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
PMCID: PMC2584289  PMID: 18636303
19.  Rupture of the Distal Biceps Tendon in a Collegiate Football Player: A Case Report 
Journal of Athletic Training  1998;33(1):62-64.
To provide health care personnel with guidelines for the management of a distal biceps tendon rupture.
Traumatic ruptures of the biceps tendon are rare, but serious, and usually involve the long head of the proximal insertion. Ruptures of the distal tendon account for only 3% of all biceps tendon ruptures. A history of tendinitis, overuse, or anabolic steroid abuse may predispose tendons to rupture. Surgical repair, followed by a comprehensive rehabilitation program, is indicated to regain full strength and range of motion in both flexion and supination.
Differential Diagnosis:
Rupture of the distal head of the biceps brachii muscle at the insertion on the radial tuberosity.
After the injury, the athlete continued to compete for the remainder of the collegiate football season. He then underwent surgery to repair the tendon at its insertion. Post- operatively, the athlete was immobilized in a cast and then a brace to prevent any movement of the muscle. Rehabilitation proceeded with isometric exercises and manual resistive exercises of the shoulder and wrist. At 16 weeks, the athlete was cleared for biceps curls and wrist supination. At 6 months, the athlete had regained full use of the muscle.
This is a relatively rare injury, usually occurring at the proximal tendon insertion and in those who are middle aged (30 to 50 years old). Also, the surgical intervention in this case was delayed without detrimental effects to the patient.
This study shows that, while surgical intervention to repair a ruptured distal biceps tendon is necessary, appropriate conservative measures can be taken to allow surgery to be delayed without harm to the patient. The athletic trainer should be aware of how to recognize and treat this injury.
PMCID: PMC1320378  PMID: 16558487
biceps brachii; upper extremity; tendinitis
20.  A randomized controlled trial of nonoperative treatment versus open reduction and internal fixation for stable, displaced, partial articular fractures of the radial head: the RAMBO trial 
The choice between operative or nonoperative treatment is questioned for partial articular fractures of the radial head that have at least 2 millimeters of articular step-off on at least one radiograph (defined as displaced), but less than 2 millimeter of gap between the fragments (defined as stable) and that are not associated with an elbow dislocation, interosseous ligament injury, or other fractures. These kinds of fractures are often classified as Mason type-2 fractures. Retrospective comparative studies suggest that operative treatment might be better than nonoperative treatment, but the long-term results of nonoperative treatment are very good. Most experts agree that problems like reduced range of motion, painful crepitation, nonunion or bony ankylosis are infrequent with both nonoperative and operative treatment of an isolated displaced partial articular fracture of the radial head, but determining which patients will have problems is difficult. A prospective, randomized comparison would help minimize bias and determine the balance between operative and nonoperative risks and benefits.
The RAMBO trial (Radial Head – Amsterdam – Amphia – Boston - Others) is an international prospective, randomized, multicenter trial. The primary objective of this study is to compare patient related outcome defined by the ‘Disabilities of Arm, Shoulder and Hand (DASH) score’ twelve months after injury between operative and nonoperative treated patients. Adult patients with partial articular fractures of the radial head that comprise at least 1/3rd of the articular surface, have ≥ 2 millimeters of articular step-off but less than 2 millimeter of gap between the fragments will be enrolled. Secondary outcome measures will be the Mayo Elbow Performance Index (MEPI), the Oxford Elbow Score (OES), pain intensity through the ‘Numeric Rating Scale’, range of motion (flexion arc and rotational arc), radiographic appearance of the fracture (heterotopic ossification, radiocapitellar and ulnohumeral arthrosis, fracture healing, and signs of implant loosening or breakage) and adverse events (infection, nerve injury, secondary interventions) after one year.
The successful completion of this trial will provide evidence on the best treatment for stable, displaced, partial articular fractures of the radial head.
Trial registration
The trial is registered at the Dutch Trial Register: NTR3413.
PMCID: PMC4109703  PMID: 24885637
Radial head; Mason type 2; Operative; Nonoperative; Open reduction; Internal fixation; Randomized controlled trial
Background and Purpose:
Distal biceps brachii tendinosis is a relatively uncommon clinical diagnosis seen by physical therapists. As a result, there is little evidence guiding clinical decisions regarding best practice or effective treatment options to restore individuals to their previous level of function. The purpose of this case report is to describe the use of eccentric training as the primary intervention in the rehabilitation of a patient with distal biceps tendinosis.
Case Description:
A 41-year-old male electrician and collegiate wrestling coach presented to a university outpatient physical therapy clinic with a two month duration of pain in the right antecubital space which occurred when the patient was performing close-grip body weight curl ups for the first time. Sharp pain was noted in the right arm during the lowering phase of the exercise. Following the examination, distal biceps tendinosis appeared to be the likely diagnosis. The patient was educated in eccentric exercise principles and was prescribed eccentric loading exercises for the distal biceps brachii tendon in two different positions of elbow flexion.
The patient was seen in physical therapy for three visits over the course of four weeks. Following eccentric training, the patient reported decreased pain, demonstrated increased right elbow flexion and forearm supination strength, was no longer tender to palpation of the distal biceps tendon and showed clinically significant improvement in QuickDASH scores.
Given the lack of available research on the rehabilitation of distal biceps tendinosis, eccentric training showing benefits with other upper quarter tendinoses and the positive outcomes in this case, it may be appropriate for physical therapists to employ eccentric training for patients with distal biceps tendinosis.
Level of Evidence:
5 (Single case report)
PMCID: PMC3414073  PMID: 22893861
distal biceps; eccentric exercise; tendinosis
22.  Clinical Results of Technique for Double Bundle Anterior Cruciate Ligament Reconstruction Using Hybrid Femoral Fixation and Retroscrew 
Clinics in Orthopedic Surgery  2011;3(4):285-294.
Anatomic anterior cruciate ligament (ACL) reconstruction has been presented as a means to more accurately restore the native anatomy of this ligament. This article describes a new method that uses a double bundle to perform ACL reconstruction and to evaluate the clinical outcome.
Grafts are tibialis anterior tendon allograft for anteromedial bundle (AMB) and hamstring tendon autograft without detachment of the tibial insertion for posterolateral bundle (PLB). This technique creates 2 tunnels in both the femur and tibia. Femoral fixation was done by hybrid fixation using Endobutton and Rigidfix for AMB and by biointerference screw for PLB. Tibial fixations are done by Retroscrew for AMB and by native insertion of hamstring tendon for PLB. Both bundles are independently and differently tensioned. We performed ACL reconstruction in 63 patients using our new technique. Among them, 47 participated in this study. The patients were followed up with clinical examination, Lysholm scales and International Knee Documentation Committee (IKDC) scoring system and radiological examination with a minimum 12 month follow-up duration.
Significant improvement was seen on Lachman test and pivot-shift test between preoperative and last follow-up. Only one of participants had flexion contracture about 5 degrees at last follow-up. In anterior drawer test by KT-1000, authors found improvement from average 8.3 mm (range, 4 to 18 mm) preoperatively to average 1.4 mm (range, 0 to 6 mm) at last follow-up. Average Lysholm score of all patients was 72.7 ± 8.8 (range, 54 to 79) preoperatively and significant improvement was seen, score was 92.2 ± 5.3 (range, 74 to 97; p < 0.05) at last follow-up. Also IKDC score was normal in 35 cases, near normal in 11 cases, abnormal in 1 case at last follow-up.
Our new double bundle ACL reconstruction technique used hybrid fixation and Retroscrew had favorable outcomes.
PMCID: PMC3232356  PMID: 22162791
KAnterior cruciate ligament reconstruction; Double bundle; Anatomical; Hybrid fixation; Retroscrew
23.  Dislocation of the Elbow: A Retrospective Multicentre Study of 86 Patients 
The objective of this retrospective multicentre cohort study was to prospectively assess the long-term functional outcomes of simple and complex elbow dislocations.
We analysed the hospital and outpatient records of 86 patients between 01.03.1999 and 25.02.2009 with an elbow dislocation. After a mean follow-up of 3.3 years, all patients were re-examined at the outpatient clinic for measurement of different outcomes.
The mean range of motion was ROM 135.5°. The Mayo elbow performance index (MEPI) scored an average of 91.9 (87.5% of the patients were rated excellent or good). The average Quick disabilities of the arm, shoulder and hand (Quick- DASH) score was 9.7, the sports/music score 11.5 and work score 6.1. The Oxford function score was 75.7, Oxford pain score 75.2 and Oxford social-psychological score 73.9.
Elbow dislocation is a mild disease and generally, the outcome is excellent. Functional results might improve with early active movements.
PMCID: PMC2845787  PMID: 20352027
Elbow; elbow joint; injury; dislocations.
24.  A Comparison of Ulnar Shortening Osteotomy Alone Versus Combined Arthroscopic Triangular Fibrocartilage Complex Debridement and Ulnar Shortening Osteotomy for Ulnar Impaction Syndrome 
Clinics in Orthopedic Surgery  2011;3(3):184-190.
This study compared the results of patients treated for ulnar impaction syndrome using an ulnar shortening osteotomy (USO) alone with those treated with combined arthroscopic debridement and USO.
The results of 27 wrists were reviewed retrospectively. They were divided into three groups: group A (USO alone, 10 cases), group B (combined arthroscopic debridement and USO, 9 cases), and group C (arthroscopic triangular fibrocartilage complex [TFCC] debridement alone, 8 cases). The wrist function was evaluated using the modified Mayo wrist score, disabilities of the arm, shoulder and hand (DASH) score and Chun and Palmer grading system.
The modified Mayo wrist score in groups A, B, and C was 74.5 ± 8.9, 73.9 ± 11.6, and 61.3 ± 10.2, respectively (p < 0.05). The DASH score in groups A, B, and C was 15.6 ± 11.8, 19.3 ± 11.9, and 33.2 ± 8.5, respectively (p < 0.05). The average Chun and Palmer grading score in groups A and B was 85.7 ± 8.9 and 84.7 ± 6.7, respectively. The difference in the Mayo wrist score, DASH score and Chun and Palmer grading score between group A and B was not significant (p > 0.05).
Both USO alone and combined arthroscopic TFCC debridement with USO improved the wrist function and reduced the level of pain in the patients treated for ulnar impaction syndrome. USO alone may be the preferred method of treatment in patients if the torn flap of TFCC is not unstable.
PMCID: PMC3162198  PMID: 21909465
Ulnar impaction syndrome; Triangular fibrocartilage complex; Ulnar shortening osteotomy; Arthroscopic debridement
25.  Surgical outcomes following nerve transfers in upper brachial plexus injuries 
Brachial plexus injuries represent devastating injuries with a poor prognosis. Neurolysis, nerve repair, nerve grafts, nerve transfer, functioning free-muscle transfer and pedicle muscle transfer are the main surgical procedures for treating these injuries. Among these, nerve transfer or neurotization is mainly indicated in root avulsion injury.
Materials and Methods:
We analysed the results of various neurotization techniques in 20 patients (age group 20-41 years, mean 25.7 years) in terms of denervation time, recovery time and functional results. The inclusion criteria for the study included irreparable injuries to the upper roots of brachial plexus (C5, C6 and C7 roots in various combinations), surgery within 10 months of injury and a minimum follow-up period of 18 months. The average denervation period was 4.2 months. Shoulder functions were restored by transfer of spinal accessory nerve to suprascapular nerve (19 patients), and phrenic nerve to suprascapular nerve (1 patient). In 11 patients, axillary nerve was also neurotized using different donors - radial nerve branch to the long head triceps (7 patients), intercostal nerves (2 patients), and phrenic nerve with nerve graft (2 patients). Elbow flexion was restored by transfer of ulnar nerve motor fascicle to the motor branch of biceps (4 patients), both ulnar and median nerve motor fascicles to the biceps and brachialis motor nerves (10 patients), spinal accessory nerve to musculocutaneous nerve with an intervening sural nerve graft (1 patient), intercostal nerves (3rd, 4th and 5th) to musculocutaneous nerve (4 patients) and phrenic nerve to musculocutaneous nerve with an intervening graft (1 patient).
Motor and sensory recovery was assessed according to Medical Research Council (MRC) Scoring system. In shoulder abduction, five patients scored M4 and three patients M3+. Fair results were obtained in remaining 12 patients. The achieved abduction averaged 95 degrees (range, 50 - 170 degrees). Eight patients scored M4 power in elbow flexion and assessed as excellent results. Good results (M3+) were obtained in seven patients. Five patients had fair results (M2+ to M3).
PMCID: PMC2845356  PMID: 20368849
Nerve transfers; root avulsions; upper brachial plexus injury

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