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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.  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
4.  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
5.  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
6.  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
7.  Distal Biceps Brachii Tendon: The Spectrum of Strain 
An injured tendinous attachment of the distal biceps brachii to the radial tuberosity was diagnosed in fifteen male patients. One additional patient sustained a first-degree strain of the distal biceps musculotendinous junction. Conservative treatment was effective for the two patients representing first-degree strains. Five patients with second-degree, partial tears were treated conservatively and experienced an average recovery time of over one year. Two patients with partial tears required a surgical reattachment of the biceps to the radial tuberosity for relief of symptoms. The Boyd-Anderson technique was used on six patients with complete ruptures. One complete separation was repaired three years post-injury by reattaching the distal biceps tendon to the brachialis. Post-operative Cybex evaluation demonstrated return to near-normal levels of strength, endurance, and total work in both flexion and supination following early reattachment to the radial tuberosity.
PMCID: PMC2328970
8.  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
9.  Endoscopic Repair of Proximal Hamstring Avulsion 
Arthroscopy Techniques  2013;2(1):e35-e39.
Hamstring muscle injuries are common in athletes and mostly consist of sprains at the myotendinous junction, which often respond well to conservative treatment. Proximal hamstring avulsion injuries, though less common, can be severely debilitating. This injury is often seen in water skiers but has been described in many other sports and in middle-aged patients. Complete avulsions in young and active individuals do not respond well to conservative treatment and may require surgical repair. In contrast, many partial tears may be treated nonoperatively. However, when symptoms continue despite a trial of extensive therapy, surgery may be warranted. Traditional surgery for proximal hamstring repair is performed with the patient in the prone position with an incision made longitudinally or along the gluteal fold, followed by identification of the torn tendons and fixation to the ischial tuberosity. We describe a novel surgical technique for endoscopic repair of proximal hamstring avulsion injuries.
PMCID: PMC3678606  PMID: 23767008
10.  Sonography of the bicipitoradial bursa 
Journal of Ultrasound  2012;15(1):39-41.
Serous bursae consist of a synovial membrane enveloping a film of liquid. They are located at interfaces between moving structures where friction must be reduced. The bicipitoradial bursa lies between the distal tendon of the biceps brachii, which it surrounds, and the radial tuberosity. It is a relatively large bursa, with dimensions ranging from 2.4 to 3.9 cm. It sometimes presents septation. It does not communicate with the joint cavity, but it may communicate with the interosseous bursa of the elbow. Regardless of its cause, bicipitoradial bursitis presents as a mass in the cubital fossa and/or with neurological symptoms (sensorial and/or motorial) caused by compression of the radial nerve. On ultrasonography, the inflamed bursa is visualized as an anechoic formation surrounding the distal biceps tendon. In addition to its role in diagnosing the bursitis, sonography can provide information about radial nerve injury (in the presence of macroscopic damage), and it can also be used for guidance during intrabursal injections.
PMCID: PMC3558081  PMID: 23396577
Bicipitoradial bursa; Distal tendon of the biceps brachii; Ultrasonography
11.  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
12.  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
13.  Triple endobuttton technique for the treatment of acute complete acromioclavicular joint dislocations: preliminary results 
International Orthopaedics  2010;35(4):555-559.
Numerous procedures have been described for the operative management of acromioclavicular (AC) joint injuries. Some of these techniques, including hardware fixation and non-anatomical reconstructions, are associated with serious complications and high failure rates. Recently, AC joint reconstruction techniques have focused on anatomical restoration of the coracoclavicular ligaments to achieve optimal clinical outcomes. We used a triple endobutton technique to separately reconstruct the trapezoid and the coronoid portions of the coracoclavicular ligament. We evaluated the preliminary clinical and radiological results of this technique in patients with acute complete dislocation of the AC joint. All patients achieved a significant improvement in the pain and function of shoulder at a mean follow-up interval of 12 months (range, 8–14 months). Excellent reduction of the AC joint was maintained. The triple endobutton technique may be safe and effective for the treatment of acute complete AC joint dislocations.
PMCID: PMC3066326  PMID: 20517694
14.  Cross Pins versus Endobutton Femoral Fixation in Hamstring Anterior Cruciate Ligament Reconstruction: Minimum 4-Year Follow-Up 
We aimed to compare cross-pin fixation and Endobutton femoral fixation for hamstring anterior cruciate ligament (ACL) reconstruction with respect to clinical and radiographic results, including tunnel widening and the progression of knee osteoarthritis (OA).
Materials and Methods
Between August 2002 and August 2005, 126 autogenous hamstring ACL reconstructions were performed using either cross pins or Endobutton for femoral fixation. Fifty-six of 75 patients in the cross-pin group and 35 of 51 patients in the Endobutton group were followed up for a minimum of 4 years. We compared the clinical and radiological results between the groups using the International Knee Documentation Committee (IKDC) evaluation form, the KT-2000 arthrometer side to side difference, the amount of tunnel widening and the advancement of OA on radiographs.
There were no significant differences in the IKDC grades between the groups at the 4 year follow-up. There was no significant difference in the side to side difference according to KT-2000 arthrometer testing. Also, there were no significant differences in terms of tunnel widening or advancement of OA on radiographs.
Endobutton femoral fixation showed good results that were comparable to those of cross pins fixation in hamstring ACL reconstruction.
PMCID: PMC3341815  PMID: 22570850
Anterior cruciate ligament reconstruction; Hamstring tendon; Graft fixation; Tunnel widening
15.  One- Versus Two-Incision Technique for Distal Biceps Tendon Repair 
HSS Journal  2008;4(2):117-122.
There are several techniques that have been described for distal biceps tendon repair but there is still controversy regarding the optimal technique. Our hypothesis is that the single-incision technique will have a similar complication rate and functionally equivalent restoration of function compared with the two-incision approach. A retrospective review of consecutive biceps tendon repairs was performed at one institution over a 5-year period. Thirty-six patients met the inclusion criteria and 26 were available for follow-up including subjective assessment, physical examination, and strength testing. Patients were divided into two groups based on the surgical approach utilized: 12 patients underwent single-incision repair and 14 had a two-incision repair. The average follow-up was 33 months (minimum 13; maximum 75). There were no statistically significant differences in regards to flexion strength or endurance, supination strength or endurance, or complication rates between the two techniques. In conclusion, both surgical techniques led to adequate restoration of strength with a low complication rate. Both techniques are safe to perform and should be guided by surgeon comfort with the approach.
PMCID: PMC2553175  PMID: 18815854
16.  3D Bicipital Groove Shape Analysis and Relationship to Tendopathy 
Journal of Digital Imaging  2007;21(2):219-234.
The bicipital groove of the proximal humerus is formed by the medial and lateral tuberosities and serves to retain the long biceps tendon in its proper place as the arm moves. Bicipital root and proximal tendon disorders are an important symptom generator in the shoulder. The accuracy of the diagnosis of many shoulder disorders visually without quantitative shape analysis is limited, motivating a clinical need for some ancillary method to assess the proximal biceps. In previous studies, measurements of bicipital groove shape were 2-dimensional (2D), taken from a single axial slice. Because of significant variations in groove shape from one axial slice to another in a single patient, such approaches risk overlooking shape features important to long biceps tendon pathology. In this paper, we present a study of the relationship between bicipital groove shape and long biceps tendon pathology using a novel 3-dimensional (3D) shape descriptor for the bicipital groove. In addition to providing quantitative measures of the shape of the groove and its relation to tendopathy, the new descriptor allows for intuitive, descriptive visualization of the shape of the groove.
PMCID: PMC3043862  PMID: 17342555
Bicipital groove; intertubercular sulcus; long biceps tendon; musculoskeletal disorder; 3D shape analysis
17.  The biceps tendons: From the top and from the bottom 
Journal of Ultrasound  2011;15(1):29-38.
The biceps brachii muscle, which inserts proximally onto the scapula and distally onto the forearm, has several tendons with numerous anatomic peculiarities, which render their sonographic examination highly variable. Proximally, the tendon of the short head of the biceps inserts onto the coracoid process and that of the long head on the superior aspect of the glenoid. The distal biceps tendon is bifurcated, and it generally inserts on the radial tuberosity, around which it rolls during pronation/supination. There is a third distal structure, the Lacertus fibrosus, an aponeurosis that branches off from the medial aspect of the tendon, crossing the median artery and median nerve, and inserting on the superficial aponeurosis of the flexor muscles. The sonographic examination of these tendons focuses on nine separate zones of interest: the glenoid insertion of the long head, its extension to the upper pole of the humeral head, the rotator interval, the reflection to the upper bicipital groove, the bicipital groove, the upper myotendinous junction, the lower myotendinous junction, the distal tendon(s), and the inferior enthesis. Because of their morphological and topographical characteristics, the biceps tendons are subject to a variety of lesions, some of which are frequently misdiagnosed on the basis of clinical findings. Ultrasound plays an important role in detecting and characterizing these lesions. Proper examination of the biceps (the distal portion in particular) is a difficult task that cannot be improvised.
PMCID: PMC3558247  PMID: 23397031
Ultrasonography; Biceps; Biceps Tendon
18.  Biceps femoris tendon injuries sustained while playing hockey 
BMJ Case Reports  2011;2011:bcr1020103466.
A 42-year-old female nurse presented in March 2008 with a left proximal hamstring tendon injury sustained while playing hockey. At surgery, the proximal biceps femoris tendon and semitendonosus were found to be ruptured and were repaired. The patient made a good recovery but sustained a further hockey injury in January 2010 involving a complete tear and rupture of the biceps femoris tendon distally. This was managed conservatively and the patient was able to return to playing hockey 10 months later. Biceps femoris tendon injuries have been reported in sport but this is the first documented case of the injury occurring while playing hockey and is also the first reported case of a biceps tendon rupture proximally (hamstring tendon) followed by distal biceps femoris rupture at the knee in the same leg.
PMCID: PMC3062872  PMID: 22715185
19.  Late repair of simultaneous bilateral distal biceps brachii tendon avulsion with fascia lata graft 
A 50 year old rock climber sustained a bilateral rupture of the distal biceps brachii tendons. He retained some flexion power in both arms but minimal supination, being weaker on the non-dominant right side. As the patient presented late, with retraction and shortening of the biceps muscle bellies, reconstruction was carried out using fascia lata grafts on both sides. Because of residual weakness on the left (dominant) side, three further surgical procedures had to be carried out to correct for elongation of the graft. A functionally satisfactory outcome, comparable with that on the right side, was eventually obtained. In summary, bilateral fascia lata grafts to bridge the gap between the retracted biceps bellies and the radial tuberosities were successful in restoring function and flexion power to the elbow. Despite being the stronger side, the dominant arm did not respond as well to the initial surgery. This may be due to overuse of this arm after the operation. 

PMCID: PMC1756182  PMID: 10450488
20.  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
21.  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
22.  Nonoperative Treatment of Distal Biceps Brachii Musculotendinous Partial Rupture: A Report of Two Cases 
Case Reports in Orthopedics  2013;2013:970512.
Musculotendinous ruptures of the distal biceps brachii are extremely rare injuries whose clinical presentation is similar to distal biceps avulsion. We describe two cases of patients who suffered a distal biceps brachii musculotendinous partial rupture. The first patient was playing soccer as goalkeeper and experienced sudden pain while throwing the ball overhead with his left arm. The second patient experienced sudden pain while weightlifting with his right arm. The mechanism of injury was the same in the two cases, as both involved glenohumeral elevation with elbow extension and forearm supination. Neither of these two patients underwent surgical repair or rehabilitation, and both had perfect scores of 100 on the Mayo Clinic Performance Index for the Elbow at one-year followup.
PMCID: PMC3730206  PMID: 23956903
23.  Arthroscopic Suprapectoral Tenodesis of the Long Head Biceps: Reproducing an Anatomic Length-Tension Relationship 
Arthroscopy Techniques  2012;1(1):e127-e132.
Tenodesis is an accepted treatment option in the management of pathology involving the long head of the biceps (LHB). Among the common causes for revision surgery after tenodesis are residual pain within the bicipital groove, cramping, early biceps fatigue, and biceps deformity. Most technical descriptions of arthroscopic biceps tenodesis involve fixation of the LHB tendon within or proximal to the intertubercular sulcus and thus fail to address the described sources of pain within this proximal anatomic location. Suprapectoral tenodesis offers the surgeon the ability to remove the LHB from within the bicipital groove by fixating the biceps more distally. Cramping, early fatigue, and biceps deformity have been described when the appropriate length-tension relation of the biceps tendon has not been restored after LHB tenodesis. Our described procedure allows for a more consistent restoration of the anatomic length-tension relation of the LHB, therefore reducing the symptoms associated with this variable. This all-arthroscopic, suprapectoral biceps tenodesis with interference fixation addresses the most common causes for revision surgery and offers a comprehensive solution for LHB pathology.
PMCID: PMC3678639  PMID: 23766967
24.  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
25.  The Effect of Fixation Technique on Graft Position in Anterior Cruciate Ligament Reconstruction 
The purpose of this paper was to determine the extent to which the technique used in ACL reconstruction and fixation influences graft placement.
This is a Comparative Radiographic cohort study.
Precise graft placement is one of the most crucial components of a successful anterior cruciate ligament (ACL) reconstruction. Two commonly used techniques of ACL reconstruction are arthroscopic bone-patellar tendon-bone (B-PT-B) autograft with interference screw fixation and semitendinosus and gracilis (ST + G) tendon autograft with endobutton femoral and multiple staple belt buckle tibial fixation. Using radiographic measurements of bone tunnel position following ACL reconstruction this study quantified the extent to which these techniques influenced graft placement.
Femoral and tibial tunnel position in ACL reconstruction was determined using the post-operative radiographs of 40 male patients who had undergone ACL reconstruction (20 B-PT-B and 20 ST+ G). The primary outcome measure was location of bone tunnel position following ACL reconstruction. Measurements were based on the guidelines of Amis et al.
Femoral tunnel position of B-PT-B grafts was an average of 9.36% more anterior in the sagittal plane than with ST + G grafts. The mean position of B-PT-B grafts was at 31.11% (SD= 5.45%). The mean position of the ST + G grafts was 21.76% (SD= 6.62%). This difference between the two was found to be significant (p<.001).
As demonstrated by this study, placement and orientation may vary to accommodate technique and fixation. Clinical outcomes measured were similar in both groups.
PMCID: PMC1888394  PMID: 14575246

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