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Purpose: To prospectively evaluate elbow flexion force, cosmetic and clinical outcome of all-arthroscopic suprapectoral biceps tenodesis for isolated biceps lesions., Methods: Tenodesis was performed using a 6.25-mm absorbable interference screw for intraosseous fixation. Seventeen out of 24 patients (70.8 %, median age 49.0 ± 10.1 years; 10 = male) could be included for 24 months follow-up. Elbow flexion strength in 10° and 90° elbow flexion, the upward-directed force of the upper arm in the O'Brien position, objective evaluation of a Popeye-sign deformity and validated clinical scores (CMS, SST, ASES) were assessed preoperatively, 3, 6, 12 and 24 months postoperatively., Results: Elbow flexion strength in 90° improved significantly from 12 months onwards (P = 0.001) without significant difference to the contralateral arm from 3 months postoperatively (n.s.). At 24 months, an average increase of 46.4 % (median 37.7 %) from preoperative could be seen. The dominant arm was affected in 70.6 %. All scores showed a significant improvement 3 months postoperatively: SST (P = 0.003), ASES (P = 0.006) and total CMS (P < 0.001). Three patients (17.6 %) developed a distalization of the maximum biceps circumference of more than 20 % compared to preoperative., Conclusions: All-arthroscopic proximal suprapectoral intraosseous single-limb biceps tenodesis for the treatment of isolated biceps lesions provides good-to-excellent clinical results with significant improvement of elbow flexion strength and clinical scores and no significant difference to the unaffected contralateral arm., Level of Evidence: IV.

Purpose: Biomechanical comparison of three different fixation techniques for a proximal biceps tenodesis., Methods: Eighteen human cadaver specimens were used for the testing. A tenodesis of the proximal biceps tendon was performed using a double-loaded suture anchor (5.5-mm Corkscrew, Arthrex), a knotless anchor (5.5-mm SwiveLock, Arthrex) or a forked knotless anchor (8-mm SwiveLock, Arthrex). Reconstructions were cyclically loaded for 50 cycles from 10-60 to 10-100 N. Cyclic displacement and ultimate failure loads were determined, and mode of failure was evaluated., Results: Cyclic displacement at 60 N revealed a mean of 3.3 ± 1.1 mm for the Corkscrew, 5.4 ± 1.4 mm for the 5.5-mm SwiveLock and 2.9 ± 1.6 mm for the 8-mm forked SwiveLock. At 100 N, 5.1 ± 2.2 mm were seen for the Corkscrew anchor, 8.7 ± 2.5 mm for the 5.5-mm SwiveLock and 4.8 ± 3.3 mm for the 8-mm forked SwiveLock anchor. Significant lower cyclic displacement was seen for the Corkscrew anchor (p < 0.020) as well as the 8-mm SwiveLock anchor (p < 0.023) compared to the 5.5-mm SwiveLock anchor at 60 N. An ultimate load to failure of 109 ± 27 N was found for the Corkscrew anchor, 125 ± 25 N were measured for the 5.5-mm SwiveLock anchor, and 175 ± 42 N were found for the 8-mm forked SwiveLock anchor. Significant differences were seen between the 8-mm SwiveLock compared to the 5.5-mm SwiveLock (p < 0.044) as well as the Corkscrew anchor (p < 0.009). No significant differences were seen between the Corkscrew and the 5.5-mm SwiveLock anchor., Conclusions: The new 8-mm forked SwiveLock anchor significantly enhances construct stability compared to a 5.5-mm double-loaded Corkscrew anchor as well as the 5.5-mm SwiveLock suture anchor. However, a restrictive postoperative rehabilitation seems to be important in all tested reconstructions in order to avoid early failure of the construct.

Purpose: Arthroscopic biceps tenodesis surgery is an important procedure for the correction of biceps tendonitis or in conjunction with rotator cuff repair with biceps symptoms. Recent trends have developed in placing the biceps tendon lower in the bicipital groove for a tenodesis. However, a more distal biceps tenodesis location is technically challenging when carried out arthroscopically with standard posterior and lateral portals. We aimed to establish the safety of a low-anterolateral portal location for direct access to the lowest aspect of the bicipital groove., Methods: An anatomical study design was used to examine portal to neurovascular structural measurements in 23 cadaveric shoulders. These shoulders had undergone low-anterolateral portal placement over the inferior most aspect of the bicipital groove as determined by palpation and direct arthroscopic visualization. No arthroscopic irrigation was performed. Following this, the shoulders underwent open dissection with the cannula in place to evaluate for any potential damage to any portion of the axillary nerve., Results: All of the resultant portals in this study provided direct access to the inferior most aspect of the bicipital groove, and the dissection revealed that the portal was touching a small distal axillary nerve branch on the undersurface of the anterior deltoid in nearly half of the shoulders., Conclusions: The placement of a low-anterolateral portal for arthroscopic biceps tenodesis at the distal bicipital groove does not produce significant neurovascular damage; the portal trajectory comes close to distal anterior branches of the axillary nerve. Given these findings, this portal should be placed bluntly to best protect these underlying neurovascular structures.

Purpose: Medial patellofemoral ligament (MPFL) reconstruction is an effective option for the treatment of recurrent patellar instability. Most techniques utilize the passage of a tendon graft through tunnels at the patella with the risk of patellar fracture. The purpose of this study was to investigate the strength of the recent MPFL reconstruction techniques (transverse tunnel, interference screw, anchor, and docking technique)., Methods: Thirty-six saw bones were divided into four groups (transverse tunnel, interference screw, anchor fixation, and docking technique) with nine patellae in each. Patella-tendon constructs were pre-loaded to 10 N and cyclically loaded for 20 cycles from 2 to 30 N under load control at a rate of 5 N/sec. The construct was then tested to failure at a constant displacement rate of 6 mm/sec. Ultimate load (N), stiffness (N/mm), and failure mode were recorded for each specimen., Results: The docking group had lower ultimate load [106 (SD 41) N] and stiffness [14 (SD 2) N/mm] values than the other groups tested (P = 0.007). The anchor group had lower stiffness [21 (SD 6) N/mm] values than the tunnel group [28 (SD 3) N/mm (P = 0.01)] and the interference screw group [31 (SD 6) N/mm, (P = 0.004)]. There was no significant difference in the ultimate load between anchor [299 (SD 116) N], tunnel [304 (SD 140) N], and interference screw groups [241 (SD 103) N] (n.s.)., Conclusion: Aperture fixation techniques, especially interference screw fixation, were as strong as the technique utilizing tunnels in the patella for MPFL reconstruction.

Purpose: A secure tibial press-fit technique in posterior cruciate ligament reconstructions is an interesting technique because no hardware is necessary. For anterior cruciate ligament (ACL) reconstruction, a few press-fit procedures have been published. Up to the present point, no biomechanical data exist for a tibial press-fit posterior cruciate ligament (PCL) reconstruction. The purpose of this study was to characterize a press-fit procedure for PCL reconstruction that is biomechanically equivalent to an interference screw fixation., Methods: Quadriceps and hamstring tendons of 20 human cadavers (age: 49.2 ± 18.5 years) were used. A press-fit fixation with a knot in the semitendinosus tendon (K) and a quadriceps tendon bone block graft (Q) were compared to an interference screw fixation (I) in 30 porcine femora. In each group, nine constructs were cyclically stretched and then loaded until failure. Maximum load to failure, stiffness, and elongation during failure testing and cyclical loading were investigated., Results: The maximum load to failure was 518 ± 157 N (387-650 N) for the (K) group, 558 ± 119 N (466-650 N) for the (I) group, and 620 ± 102 N (541-699 N) for the (Q) group. The stiffness was 55 ± 27 N/mm (18-89 N/mm) for the (K) group, 117 ± 62 N/mm (69-165 N/mm) for the (I) group, and 65 ± 21 N/mm (49-82 N/mm) for the (Q) group. The stiffness of the (I) group was significantly larger (P = 0.01). The elongation during cyclical loading was significantly larger for all groups from the 1st to the 5th cycle compared to the elongation in between the 5th to the 20th cycle (P < 0.03)., Conclusion: All techniques exhibited larger elongation during initial loading. Load to failure and stiffness was significantly different between the fixations. The Q fixation showed equal biomechanical properties compared to a pure tendon fixation (I) with an interference screw. All three fixation techniques that were investigated exhibit comparable biomechanical properties. Preconditioning of the constructs is critical. Clinical trials have to investigate the biological effectiveness of these fixation techniques.

Purpose: Intensive scheduling in sports requires athletes to resume physical activity shortly after injury. The purpose of this study was to investigate early isokinetic muscle strength and knee function on bone-patellar tendon-bone (BPTB) ACL reconstruction with double femoral pin fixation or interference screw technique., Methods: A prospective study was conducted from 2008 to 2009, with 48 athletes who received femoral BPTB fixation with interference screw (n = 26) or double pin (n = 22). Clinical (IKDC objective score and hop test) and isokinetic muscle strength (peak torque (PT), PT/body weight and flexion/extension rate (F/E) in 60 and 240°/s) were analyzed at 6 months of follow-up., Results: Analysis at baseline showed no differences between groups before surgery related to age, gender, associated injury, Tegner or Lysholm score; thus showing that groups were similar. During follow-up, however, there were significant differences between the two groups in some of the isokinetic muscle strength: PT/BW 60°/s (Double Pin = 200% ± 13% vs. Interference Screw = 253% ± 16%*, *P = 0.01); F/E 60°/s (Double Pin = 89% ± 29%* vs. Interference Screw = 74% ± 12%, *P = 0.04). No statistical differences between groups were observed on IKDC objective score, hop test and complications., Conclusion: The significant muscle strength outcome of the interference screw group found in this study gives initial evidence that this fixation technique is useful for athletes that may need accelerated rehabilitation. Early return to sports ability signaled by isokinetic muscle strength is of clinical relevance as it is one of the main goals for athletes' rehabilitation.

Purpose: To investigate two different methods of suture fixation and tendon behaviour when using an Endobutton and a tripled tendon., Methods: Thirty bovine tendons and foam blocks were randomly allocated to three groups: group 1: The tendon was doubled through 40-mm Endobutton; group 2: Tripled tendon--whip-stitched with No. 2 Ultrabraid, passed through an Endobutton and third limb secured to the loop via seven knots; and group 3: Tripled tendon--whip-stitched with No. 2 Fibreloop and fixed as group 2. A tunnel matching the graft diameter was drilled through the block. The graft was passed through the tunnel and fixed with an interference screw. The constructs were cycled at 1 Hz from 10 to 50 N for 10 cycles followed by 50-250 N at 1 Hz for 500 cycles. Load-to-failure test was then carried out at a rate of 20 mm/min. A custom digital image capture technique was used to measure and calculate displacement, strain and stress. Statistical analysis was carried out using Kruskal-Wallis test and paired t test., Results: There was no statistical significant difference between ultimate tensile strength (UTS) (P = 0.35) and yield load (0.41) between the 3 groups. The mean displacement of the third tendon limb in group 2 was 4.8 mm and in group 3, 1.5 mm. Displacement was not statistically significant (P = 0.07). The mean stress in the third limb versus the doubled portion of tendon in group 2 was 0.4 ± 0.02 versus 4.8 ± 0.52 MPa and in group 3, 0.5 ± 0.03 versus 5.2 ± 0.52 MPa., Conclusions: In this biomechanical study, there was no mechanical difference in the overall properties between a doubled and tripled tendon graft. Significant cyclic elongation occurred in the third limb of the tripled tendon in comparison with the doubled portioned. Further work is needed to determine whether these mechanical findings translate to clinical practice. Caution should be used when tripling hamstring grafts. In particular, tripling small grafts provides no biomechanical advantage immediately and possibly long term, thus potentially increasing the risk of failure.

Purpose: Fixation of soft tissue grafts with interference screws relies on the friction of the graft between the screw and the bone tunnel. The goal of this study was to precondition such grafts by mechanical compression in order to reduce anticipated and undesired viscoelastic adaptation of the graft to screw pressure. Further, the otherwise slippery graft surface was modified with impressed tricalcium phosphate granules (TCP) to improve friction and mechanical hold., Methods: Fresh flexor digitorum tendons from young bovines were used to create bundles with a diameter of 8-9 mm and were divided into 10 groups to compare the pullout strength and bone damage in a variety of construct scenarios. Specifically, the effects of graft precompression to reduce preimplantation graft diameter were investigated. Further the effects of impressing TCP granules and/or a screw thread into the tendon surface during the compression process were studied., Results: In sawbone tests, radial graft compression allowed for a smaller bone tunnel (7 mm), but resulted in a significantly lower pullout strength of 174 N (95% CI: 97, 250), compared with controls [315 N (204, 426)]. In contrast, TCP coated [402 N (243, 561)], screw embossed grafts [458 N (302, 614)], and the combination of TCP and embossing [409 N (274, 543)] achieved higher pullout strengths when compared to the standard technique. In porcine bone, untreated grafts using an 8 mm screw pulled out at 694 ± 93 N, significantly higher loads were required to pullout compressed grafts with or without TCP coating (870 ± 74 and 878 ± 131 N), yet fixed with a 7 mm screw., Conclusion: Modification of the tendon graft surface has a large influence on the biomechanical performance of interference screw fixation and results in less bone damage inflicted during insertion to a smaller tunnel diameter, while simultaneously achieving superior pullout strength.

Purpose: This study was designed to present the novel technique of intramedullary cortical button fixation for distal biceps tendon repair via a single-limited anterior portal., Methods: To reattach the ruptured biceps tendon at the radial tuberosity, two Bicepsbutton(™) (Arthrex, Naples, FL, USA) were intramedullary positioned to the anterior cortex. The surgical procedure is described in detail. This technique has been performed in a first series of 3 patients with acute distal biceps tendon ruptures., Results: All patients were very satisfied after surgery and would undergo the same surgical procedure again. All patients regained full range of elbow motion with comparable strength of forearm supination and elbow flexion measured against the uninjured arm at 6 months of follow-up. No neurovascular complications have been occured., Conclusion: Double intramedullary cortical button repair has shown to be a safe and reliable fixation method for distal biceps tendon rupture in a small series of patients. Preliminary results are encouraging.

Different surgical techniques exist for biceps tenodesis. The most secure fixation technique is with interference screws. The purpose of the study was to compare the biomechanical performance of three different interference screw biceps tenodesis fixation methods, which involve different tunnel preparation methods. Using a sheep shoulder model and metal interference screws, a bone wedge technique was compared to serial tunnel dilation and a control group. After a preload, all repairs were cyclically loaded (20-60 N) for 100 cycles followed by destructive testing. Biceps tenodesis using an interference screw--bone wedge technique showed statistically lower cyclic displacement (8.1 ± 6.4 mm) than serial dilatation with an interference screw (21.3 ± 8.4 mm) or interference screw fixation alone (18.3 ± 8.3 mm) (P = 0.02). There were no statistically significant differences in ultimate failure strength for any of the interference screw biceps tenodesis techniques tested. The tunnel preparation method chosen for interference screw fixed biceps tenodesis can have a positive effect on tenodesis performance. Using the bone wedge technique may allow a more rapid rehabilitation program applicable for the traumatic biceps tendon rupture seen in young, athletic patients with high demands.

We encountered some complications during the graft passage and fixation using a TransFix implant. Despite the large number of cases and publications related to the ligament surgery, few papers have reported intra-operative complications. We report our experience of such complications and prevention methods. From June 2005 to October 2007, anterior cruciate ligament reconstructions were performed in 128 patients using the TransFix devices. From the surgical records, the opinions of the assistant during the graft passage were divided into three subsets: tight, modest, and loose. The results were also analyzed according to the use of the routine procedure, vertical traction, and thigh portal. Complications during the graft passage and fixation were encountered in 13 patients. These complications occurred when the femoral tunnels were tight during the graft passage (P < 0.0001). The addition of vertical traction or a thigh portal decreased the number of complications significantly (P < 0.0001). The main cause of such complications was the lack of full proximal migration of the graft, which can cause tendon and wire breakage. This study introduces some methods to prevent such complications.

We describe a novel double-bundle reconstruction method for ACL deficient knee. Grafts are tibialis allograft for AMB (anteromedial bundle) and semitendinosus autograft for PLB (posterolateral bundle). Femoral fixations are done by Bio-TransFix for AMB and EndoButton for PLB. Tibial fixations are done by Bio-interference screw for AMB at 60-70 degrees knee flexion and secure the PLB and remnant AMB graft simultaneously onto anteromedial aspect of tibia at 10-20 degrees knee flexion with spiked washer and screw. With our technique, graft lengths are not restricted and we provide strong femoral and tibial fixation if it is compared with previous techniques.

Previous transtibial double bundle posterior cruciate ligament (PCL) reconstruction methods have several problems in graft length and tibial fixation. We introduce new surgical method that is less restrictive by graft length and is more stable with single tibial fixation. After diagnostic arthroscopy, we prepare the graft, ream the tibial tunnel, and perform the procedure for TransFix tibial fixation. Femoral 2 tunnel is made and graft is passed via anteromedial (AM) portal. Tibial fixation is done and femoral 2 graft is fixed sequentially at each knee position. TransFix tibial single fixation method in double bundle PCL reconstruction provides more stable fixation, more free graft selection, and prevents graft damage by passing the graft via AM portal.