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Background: A lateral extra-articular tenodesis (LET) is increasingly being utilized to augment an anterior cruciate ligament reconstruction because it has been shown to reduce the risk of postreconstruction graft failure or recurrent rotatory instability. Various femoral fixation techniques are available, including the use of an interference screw, staple, or suture anchor., Purpose: To determine and compare the biomechanical properties of an LET graft when using an interference screw, staple, or suture anchor for the femoral fixation for a modified Lemaire LET., Study Design: Controlled laboratory study., Methods: Eighteen fresh-frozen cadaveric knees were obtained and randomly assigned via a random group generator to undergo a modified Lemaire LET using either an interference screw, a staple, or a suture anchor for femoral fixation. The specimen underwent load-to-failure testing at 20 mm/min until graft failure. The maximum failure load, stiffness, and failure mode for each specimen were recorded., Results: The mean failure load was highest for the interference screw (252.7 ± 131.2 N), followed by the staple (151.8 ± 34.1 N) and the suture anchor (105.7 ± 16.4 N). There was a significant difference in failure load between the interference screw and the suture anchor ( P = .015). There was no significant difference between the staple and the interference screw ( P = .101) or the suture anchor ( P = .577). There was no significant difference in graft stiffness across all fixation methods ( P = .089)., Conclusion: All 3 femoral fixation methods achieved adequate failure loads, although the interference screw had a greater failure load than the suture anchor and there was no significant difference between these implants and the staple. There were no significant differences in stiffness between the fixation methods., Clinical Relevance: The maximum failure load occurred with an interference screw for femoral fixation of a modified Lemaire LET; however, because of socket size, this implant may be at greater risk of anterior cruciate ligament reconstruction tunnel collision compared to a smaller-diameter suture anchor drill hole. The failure load of the suture anchor was the lowest; however, it appears sufficient for stable fixation based on the force experienced by an LET graft reported in the literature., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: Funding was provided by a research grant from the Arthroscopy Association of North America. E.L.S. has received support for education from Smith & Nephew and a grant from Arthrex. R.F.L. has received consulting fees from Ossur, Smith & Nephew, and Responsive Arthroscopy; royalties from Ossur, Smith & Nephew, Elsevier, and Arthrex; research support from Ossur and Smith & Nephew; and support for education from Foundation Medical. G.M. has received consulting fees from Smith & Nephew and IBSA Pharma SAS; and speaking fees and research support from Smith & Nephew. A.G.G. has received consulting fees from Smith & Nephew; speaking fees from Ossur; and support for education from Arthrex and Medwest Associates. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

The subscapularis (SSC) muscle is a crucial anterior glenohumeral stabilizer and internal rotator of the shoulder joint. The partial tears of the SSC might result from traumatic injury or intrinsic degeneration. Partial SSC tears can range in severity and be classified into different categories based on the location of the tear, size of the lesion, and associated pathology. The tear usually begins from the superolateral margin in the first facet and propagates downwards. It is frequently associated with biceps pathology or anterosuperior lesions. These tears are now increasingly recognized as distinct pathology that requires specific diagnostic and management approaches. The current management approaches are shifting towards operative, as partial SSC tears are increasingly recognized as a distinct pathology. At present, there is no consensus regarding the timing of repair, but the relative tendency of the SSC to retract much faster than other rotator cuff muscles, and difficulty in mobilization, advocates an early repair for SSC irrespective of the lesion size. An associated biceps pathology can be treated with either tenotomy (biceps delamination/erosion) or tenodesis. The techniques of partial SSC repair are constantly improving. There is no reported difference in use of 2-anchor-based conventional single-row (SR), a 3-anchor-based interconnected double-row technique, or a 2-anchor-based interconnected hybrid double-row construct in the repair construct. However, the 2-anchor-based interconnected double-row provides an advantage of better superolateral coverage with leading-edge protection, as it helps in placing the superolateral anchor superior and lateral to the original footprint. A timely intervention and restoration of the footprint will help restore and rehabilitate the shoulder. Future directions should prioritise injury prevention, early diagnosis with clinic-radiological cues and targeted interventions to mitigate risk., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Purpose: There is limited clinical outcome data comparing fixation methods for tenodesis of the long head of the biceps tendon (LHBT), particularly button fixation. The purpose of this study was to compare clinical outcomes, patient-reported outcomes, and return to sport (RTS) between patients undergoing LHBT with bicortical versus unicortical button technique. The authors hypothesized these fixation methods would be similar for all outcomes., Methods: Patients who underwent LHBT using unicortical or bicortical button fixation with minimum 2-year follow-up were identified. Postoperative outcomes were evaluated using the American Shoulder and Elbow Surgeons (ASES) questionnaire and visual analogue scale (VAS) pain score. A sports activity survey was collected to assess baseline sport participation and ability to return to pre-injury activities. Continuous variables were analyzed using the Mann-Whitney-U test. Categorical variables were analyzed using Chi-squared tests. Multivariable logistic and linear regression were performed to determine predictors of RTS and time to RTS., Results: Sixty-four subjects (19 unicortical and 45 bicortical button fixation) were included (average follow-up 3.5 (range: 2.0-7.8) years). There were no significant differences found between button groups for VAS pain score (1.5 vs. 1.2; p = 0.876), VAS pain during sport score (1.6 vs. 1.1, p = 0.398), and ASES score (66 vs. 71; p = 0.294). There were no significant differences in rate of RTS (75.0 vs. 77.4%; p = 0.885) or average time to return to sport (11.7 ± 7.3 vs. 7.0 ± 4.0 months; p = 0.081) between groups., Conclusion: There were no significant differences in clinical outcomes, pain, or return to sport between patients who underwent LHBT with unicortical or bicortical button fixation., Competing Interests: Declarations Conflict of interest All other authors have no competing interests to declare that are relevant to the content of this article., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Background: Tenodesis of the long head of the biceps tendon is frequently performed in shoulder surgery, and all-suture anchors have become more popular as fixation methods. However, uncertainty still exists regarding the ultimate load to failure of all-suture anchors and the best insertion angle at a cortical humeral insertion point., Purpose: The purpose of this study was to compare the biomechanical characteristics of three types of all-suture anchors frequently used for biceps tenodesis. In addition, the influence of two different insertion angles was observed in a porcine humeri model., Methods: The ultimate load to failure and failure mode of three types of all-suture anchors (1.6 FiberTak®, 1.9 FiberTak®, 2.6 FiberTak®, Arthrex®) applicable for subpectoral biceps tenodesis were evaluated at 90° and 45° insertion angles in 12 fresh-frozen porcine humeri. The anchors were inserted equally alternated in a randomized manner at three different insertion sites along the bicipital groove, and the suture tapes were knotted around a rod for pullout testing. In total, 36 anchors were evaluated in a universal testing machine (Zwick & Roell)., Results: The 2.6 FiberTak® shows higher ultimate loads to failure with a 90° insertion angle (944.0 N ± 169.7 N; 537.0 N ± 308.8 N) compared to the 1.9 FiberTak® (677.8 N ± 57.7 N; 426.3 N ± 167.0 N, p-value: 0.0080) and 1.6 FiberTak® (733.0 N ± 67.6 N; 450.0 N ± 155.8 N, p-value: 0.0018). All anchor types show significantly higher ultimate loads to failure and smaller standard deviations at the 90° insertion angle than at the 45° insertion angle. The major failure mode was anchor pullout. Only the 2.6 FiberTak® anchors showed suture breakage as the major failure mode when placed with a 90° insertion angle., Conclusions: All three all-suture anchors are suitable fixation methods for subpectoral biceps tenodesis. Regarding our data, we recommend 90° as the optimum insertion angle., Clinical Relevance: The influence of anchor size and insertion angle of an all-suture anchor should be known by the surgeon for optimizing ultimate loads to failure and for achieving a secure fixation., (© 2024. The Author(s).)

Background: Various techniques have been described for distal biceps tendon reinsertion. Although high success rates have been reported, all current techniques have specific shortcomings, with complications such as heterotopic ossification, nerve damage, and gap formation. The purpose of the present study was to biomechanically evaluate a new intramedullary fixation device that might reduce the risk of posterior interosseous nerve lesions. We therefore compared the fixation strength of this new intramedullary button with an extramedullary placed classic extracortical button., Methods: A standard bicortical button was compared to the new intramedullary fixation device using fresh-frozen cadaveric specimens. The fixation strengths were tested both cyclically and statically. Load to failure and method of failure were also recorded., Results: There were no failures during the cyclic load testing. The mean tendon-bone displacement was 0.87 ± 0.13 mm for the bicortical group and 0.83 ± 0.13 mm for the new button. During static loading, the mean load to failure for the bicortical group was 296 ± 97 N, whereas the new button group showed a higher mean load to failure of 356 ± 37 N. Breakout through the anterior cortex was recorded in 2 of 6 bicortically placed buttons and 1 of 6 in the new device., Conclusions: The new intramedullary fixation device yields comparable loads to failure compared with currently used techniques in a biomechanical setup. These findings together with the theoretical advantages suggest that this technique may be a valuable solution for the repair of distal biceps tendon rupture., (Copyright © 2020 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Purpose: To compare the biomechanical characteristics of the interconnected knotless anchor (IKA) fixation with the double knotless anchor (DKA) and interference screw (IS) fixation in the suprapectoral biceps tenodesis., Methods: In total, 24 fresh-frozen human cadaveric shoulders (mean age, 67.3 ± 6 years) were used for the study. All the specimens were randomly divided into 3 experimental biceps tenodesis groups (n = 8): IKA, DKA, and IS. After tenodesis, each specimen was preloaded at 5 N for 2 minutes, followed by a cyclic loading test from 5 to 70 N for 500 load cycles. Finally, a destructive axial load to failure test (1 mm/s) was performed. All the values, including ultimate failure load, stiffness, cyclic displacement, and mode of failure were evaluated., Results: The IKA provided the highest construct stiffness (38.9 ± 7.7 N/mm) and ultimate failure load (288.3 ± 47.6 N), the results for which were statistically better than the corresponding results in the IS and DKA groups. In terms of cyclic displacement, there were no statistical differences among the 3 fixation constructs. The most common failure mode was biceps tendon tearing in IS group (7/8) and IKA group (8/8). In the contrast, suture slippage accounted for the most common failure mode in DKA., Conclusions: In suprapectoral bicep tenodesis, IKA fixation appears to offer improved construct stiffness and ultimate failure load while maintaining comparable suture slippage as compared with IS fixation or DKA fixation in the current biomechanical study., Clinical Relevance: The IKA fixation compares favorably with other techniques and could be an alternative clinical option for suprapectoral biceps tenodesis., (Copyright © 2020 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: Many biceps tenodesis (BT) procedures are described for treating proximal biceps pathology. Axillary nerve injury has been reported during BT using bicortical drilling techniques with variable results depending on the location. In addition, there is a risk of potential articular damage during suprapectoral BT. We sought to determine the distance between the axillary nerve and the posterior passage of a bicortical pin, as well as the risk of articular damage, and to analyze whether a lateral inclination of the pin could avoid the chondral risk during suprapectoral BT with bicortical drilling., Methods: Ten cadaveric shoulders were divided into 2 groups. In the first group, we determined the axillary nerve distance from the posterior exit point of 3 pins in a suprapectoral position 15 mm distal to the humeral cartilage: perpendicular, 10° caudal, and 20° caudal inclination. We measured 2 distances from the pin: to the axillary nerve and to the cartilage border. In the second group, we set one pin at the same perpendicular position and set the second pin 15° laterally tilted to determine its extra-articular passage., Results: No pin injured the nerve, whereas all pins showed a transchondral direction. The 20° caudal inclination was the nearest to the nerve (18.8 mm [95% confidence interval, 5.5-32 mm]), but the perpendicular position was the safer position (38.8 mm [95% confidence interval, 28-49.6 mm]). Tilting the pin direction 15° laterally prevented cartilage damage (P = .008)., Conclusions: Suprapectoral BT with bicortical drilling performed 15 mm distal to the humeral cartilage is a safe procedure regarding the axillary nerve. A potential humeral chondral injury could be prevented with 15° of lateral inclination of the pin guide., (Copyright © 2019 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Various arthroscopic tenodesis techniques for the treatment of long head of the biceps tendon pathologic abnormalities have been described., Purpose: This study evaluated the clinical outcomes of using a bioabsorbable interference screw and soft anchor for long head of the biceps tendon arthroscopic tenodesis., Methods: Sixty patients treated by this technique between February 2013 and March 2015 were followed up for at least 2 years. In our operative technique, after the bone hole was made just proximal to the pectoralis major, the soft anchor was inserted at the bottom of the hole. After tenotomy of the long head of the biceps tendon proximal to the bone hole, the tendon was fixed into the bottom of the hole temporarily using the soft anchor. Finally, the tendon was fixed in the hole with a bioabsorbable interference screw., Results: The UCLA score 15.1 points preoperatively and 32.4 points at follow-up (p < 0.05). The Constant 55.8 points preoperatively and 93.9 points at follow-up (p < 0.01). After biceps tenodesis, no cosmetic deformities were found in 56 patients (93.3%), and four patients (6.7%) had a Popeye deformity. On postoperative magnetic resonance evaluation, the long head of the biceps tendon was located on the bicipital groove without deviation in 53 cases (88.3%), on the bicipital groove with a partial deviation in 6 cases (10.0%), and outside the bicipital groove with complete deviation (dislocated) in 1 case (1.7%)., Conclusion: We found that arthroscopic biceps tenodesis using a soft anchor provided a reliable means for treating biceps pathology with no cosmetic deformities and with good clinical results., (Copyright © 2019 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

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

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

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

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

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

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

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

Background: Long head of the biceps tendon (LHBT) tenodesis is predominantly performed for 2 reasons: anterior shoulder pain (ASP) or structural reasons (partial tear, dislocation)., Methods: Between 2006 and 2014, all cases of primary LHBT tenodesis performed at an integrated health care system were retrospectively reviewed. Complications were analyzed by tenodesis location (below or out of the groove [OOG] vs leaving tendon in the groove [ITG]), fixation method (soft tissue vs implant), and indication (preoperative ASP vs structural)., Results: Among 1526 shoulders, persistent ASP did not differ by fixation method (11.0% for implant vs 12.8% for soft tissue, P = .550) or location (10.8% for OOG vs 12.9% for ITG, P = .472). Soft-tissue tenodesis cases had more frequent new-onset ASP (11.9% vs 2.6%, P < .001) and subjective weakness (8.50% vs 3.92%, P < .001) but less frequent revisions (0% vs 1.19%, P = .03) than implant tenodesis cases. No difference was found between ITG and OOG for persistent ASP (12.9% vs 10.8%, P = .550), new-onset ASP (6.5% vs 2.8%, P = .339), cramping (1.70% vs 2.31%, P = .737), deformity (4.72% vs 4.62%, P = .532), or subjective weakness (6.23% vs 4.32%, P = .334), but ITG cases had more revisions (1.51% vs 0.60%, P = .001). Among implant tenodesis cases, 1 shoulder (0.085%) sustained a fracture., Conclusion: The overall complication rate of LHBT tenodesis was low. Of the shoulders, 10.8% to 12.9% continued to have ASP, regardless of whether the LHBT was left ITG. Soft-tissue tenodesis cases had higher rates of new-onset ASP and subjective weakness. No significant difference for tenodesis ITG or OOG was found in biceps-related complications., (Copyright © 2018 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

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

Background: The aim of this cadaveric study was to investigate different defined drill trajectories through the radial tuberosity for the placement of a cortical button and their proximity to the posterior interosseous nerve (PIN) by using the double-incision technique., Methods: A total of 10 elbows from 5 fresh entire cadavers were used in this study. Detachment of the distal biceps tendon was performed to simulate its rupture. A standardized double-incision approach was performed, and the radial tuberosity was exposed in full pronation. A drill hole was applied perpendicular through the center of the tuberosity. Another 8 drill holes were applied with the same starting point at the tuberosity with defined trajectories. A cortical button was then placed through the center hole. The distances between the PIN and the exit holes of the different trajectories were measured. The cortical button was analyzed regarding muscle entrapment as well as its closest distance to the PIN., Results: Contact of the PIN and the drill hole was observed for 6 of the 9 trajectories; only the proximal-ulnar, ulnar, and ulnar-distal trajectories had no contact with the PIN in any of the experiments. No contact of the cortical button and the PIN was observed for the ulnar and distal-ulnar drill trajectories only. The minimal distance to the PIN was 1.6 mm for both., Conclusion: Because of the potential risk of PIN injuries, the use of cortical button fixation in combination with the double-incision approach cannot be recommended., (Copyright © 2018 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Hypothesis: We aimed to determine patient-reported outcomes in patients undergoing open subpectoral biceps tenodesis with a dual-fixation construct who had no postoperative range-of-motion or weight-bearing restrictions. Our hypothesis was that patients without postoperative restrictions would have low failure rates with improved patient-reported outcomes. We further hypothesized that this technique would allow an earlier return to activity and similar functional outcomes when compared with those reported in the literature., Methods: In this institutional review board-approved retrospective outcome study, we evaluated 105 patients who underwent primary open subpectoral biceps tenodesis with a bicortical suture button and interference screw construct without postoperative restrictions. The primary outcome measure was failure of the biceps tenodesis. Postoperative outcome scores included the Short Form 12 (SF-12) Physical Component Score; SF-12 Mental Component Score; American Shoulder and Elbow Surgeons total score and subscales; and Disabilities of the Arm, Shoulder and Hand score., Results: A total of 98 patients (85%) were available for final follow-up at an average of 3.5 years. There were 2 failures (2.2%), at 5 weeks and 9 weeks postoperatively. Four patients underwent additional surgery unrelated to the previous tenodesis procedure. Final outcome scores indicated high levels of function, including the SF-12 Physical Component Score (mean, 51.5; SD, 7.8), SF-12 Mental Component Score (mean, 54.7; SD, 6.7), American Shoulder and Elbow Surgeons total score (mean, 89.4; SD, 14.2), and Disabilities of the Arm, Shoulder and Hand score (mean, 11.3; SD, 13.4)., Conclusion: Open subpectoral biceps tenodesis using a dual-fixation construct with no postoperative motion restrictions resulted in excellent outcomes with a low incidence of failure., (Copyright © 2018. Published by Elsevier Inc.)

Background: Few studies have investigated clinical and structural outcomes after transosseous (TO) repair. The purpose of this study was to compare structural and clinical outcomes of rotator cuff tear, repaired arthroscopically, with a single row (SR) or transossoeus (TO) anchorless technique., Methods: 96 patients who underwent an arthroscopic repair for superior or posterosuperior rotator cuff tear using TO (n:54) or a SR (n:42) were retrospectively enrolled in this study after evaluation of clinical and surgical notes. Functional evaluation was performed with the adjusted Constant score, and American Shoulder and Elbow Surgeons (ASES) score. Postoperative cuff integrity was determined through MRI study., Results: Patients were recalled after a minimum follow-up of two years. All the patients were available for the study. In the SR group the Constant rating system showed a significant improvement from a preoperative average rating of 44.8 to an average of 85.7. In the group of TO repair the Constant rating system showed a significant improvement from a preoperative average of 46.1 to an average of 87.6 postoperatively. According to ASES index scores, the average total score improved from 42.8 to 92.0 in the anchor group and from 40.4 to 94.6 in the TO group. There was no statistical difference between the two groups about clinical outcomes. Postoperative MRI revealed no differences in term of complete re-tears between the two techniques. In the SR group at MRI we observe significant more cases of rotator cuff with a Sugaya type III healing., Conclusions: Arthroscopic rotator cuff repair yielded successful clinical outcomes using SR and TO technique. However using the TO technique we saw less type 3 Sugaya readings on MRI suggesting a possible benefit with TO repair., Level of Evidence Ii: Retrospective study., (Copyright © 2018 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

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

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

Background and purpose - A large number of fixation methods of hamstring tendon autograft (HT) are available for anterior cruciate ligament reconstruction (ACLR). Some studies report an association between fixation method and the risk of revision ACLR. We compared the risk of revision of various femoral and tibial fixation methods used for HT in Scandinavia 2004-2011. Materials and methods - A register-based study of 38,666 patients undergoing primary ACLRs with HT, with 1,042 revision ACLRs. The overall median follow-up time was 2.8 (0-8) years. Fixation devices used in a small number of patients were grouped according to design and the point of fixation. Results - The most common fixation methods were Endobutton (36%) and Rigidfix (31%) in the femur; and interference screw (48%) and Intrafix (34%) in the tibia. In a multivariable Cox regression model, the transfemoral fixations Rigidfix and Transfix had a lower risk of revision (HR 0.7 [95% CI 0.6-0.8] and 0.7 [CI 0.6-0.9] respectively) compared with Endobutton. In the tibia the retro interference screw had a higher risk of revision (HR 1.9 [CI 1.3-2.9]) compared with an interference screw. Interpretation - The choice of graft fixation influences the risk of revision after primary ACLR with hamstring tendon autograft.

Purpose: To quantify the torsional load to fracture for subpectoral biceps tenodesis with interference screw fixation., Methods: We randomized 28 specimens from 14 matched-pair full-length humeri (mean age, 55.3 years) into 3 groups: (1) empty ream group (ERG), (2) screw-only group (SOG), and (3) screw-plus-biceps tendon group (SBG). In each group, 1 humerus of each matched pair was prepared according to group allocation and the contralateral humerus remained intact as a control. In the ERG, an 8-mm unicortical hole was reamed 1 cm proximal to the inferior border of the pectoralis major tendon insertion; in the SOG, the humerus was filled with an 8-mm × 12-mm PEEK (polyether ether ketone) screw; and in the SBG, the humerus was filled with a PEEK screw and the cadaveric long head of the biceps tendon. Humeri were tested under torsional displacement at a rate of 1°/s until fracture. Maximum torque, energy to maximum torque, and linear stiffness were used to assess humerus strength., Results: Compared with contralateral intact specimens, the maximum torque to fracture was reduced by 28% in the ERG (P = .005), 30% in the SOG (P = .014), and 20% in the SBG (P = .046). Energy to maximum torque was similarly reduced in the ERG (P = .007), SOG (P = .023), and SBG (P = .049). Stiffness was increased by 4% in the ERG (P = .498), 9% in the SOG (P = .030), and 4% in the SBG (P = .439)., Conclusions: Drilling an 8-mm unicortical hole in zone 3 of the bicipital tunnel for open subpectoral biceps tenodesis reduces the torsional load to humeral fracture up to 28% at time 0. The addition of a PEEK tenodesis screw alone reduced the maximum torque by 30%, and the addition of a screw with the long head of the biceps tendon reduced the maximum torque by 20%. The total load to fracture was reduced in all settings. Stiffness was not significantly different for the ERG and SBG, but stiffness was significantly higher for the SOG compared with the intact matched humeri at time 0., Clinical Relevance: When performing a biceps tenodesis, humeral fracture susceptibility is increased with an applied torsional load at time 0. Thus providers must be aware of this reduced integrity when a subpectoral biceps tenodesis is used., (Copyright © 2017. Published by Elsevier Inc.)

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

Biceps tenodesis maintains the cosmetic appearance and length-tension relationship of the biceps with an associated predictable clinical outcome compared with tenotomy. Arthroscopic suprapectoral techniques are being developed to avoid the disadvantages of the open subpectoral approach. This study biomechanically compared 3 arthroscopic suprapectoral biceps tenodesis techniques performed with a suture anchor with lasso loop technique, an interference screw, and a compressive rivet. For a total of 15 randomized paired tests, 15 pairs of human cadaveric shoulders were used to test 1 technique vs another 5 times with 3 customized setups. Biomechanical testing was performed with an electromechanical testing system. The tendon was preloaded with 10 N and cyclically loaded at 0 to 40 N for 50 cycles. Load to failure testing was performed at 1 mm/s until failure occurred. The compressive rivet, interference screw, and suture anchor with lasso loop had mean load to failure of 97.1 N, 146.4 N, and 157.6 N, respectively. The difference in ultimate strength between the suture anchor with lasso loop and the compressive rivet was statistically significant (P=.04). No significant differences were found between the suture anchor with lasso loop and the interference screw (P=.93) or between the interference screw and the rivet (P=.10). When adjusted for sex, the load to failure overall among the 3 constructs was not significantly different. All 3 techniques had a different predominant mechanism of failure. The suture anchor with lasso loop showed superior load to failure compared with the compressive rivet. The minimum load to failure required to achieve clinically reliable biceps tenodesis is unknown. [Orthopedics. 2017; 40(6):e1009-e1016.]., (Copyright 2017, SLACK Incorporated.)

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.

Background: Pathologies of the long head of biceps tendon (LHB) can cause anterior shoulder pain. Surgical treatment includes tenotomy and tenodesis (TD), however TD causes fewer cosmetic deformities and less cramping of the biceps muscle. To date, numerous techniques for TD have been described but the "gold standard" has not yet been established., Objectives: The purpose of this study is to evaluate the functional and cosmetic outcome following subpectoral biceps TD with an interference screw and a cortical-button (STLHB-IC) after 1 year., Materials and Methods: 35 patients (10 female, 25 male) with an average age of 57.4 ± 7 years were examined after STLHB-IC with a follow up of 12.8 ± 1.2 months. The constant score (CS), the long head of biceps score (LHBS) and the subjective shoulder value (SSV) were assessed. Furthermore, the cosmetic result was evaluated by the patient and the examiner, and the elbow flexion strength (EFS) was measured., Results: The CS (82.5 ± 17.2), LHBS (90.1 ± 11.5) and SSV (83.2 ± 17.7) showed good and excellent results. The SSV increased significantly pre vs. postoperatively (40.6 ± 19.7 vs. 83.2 ± 17.7). The CS (82.5 ± 17.2) and the LHBS (90.1 ± 11.5), as well as the EFS (17.5 ± 4.8 kg) of the affected shoulder revealed no significant differences compared with the non-affected shoulder (CS: 91.8 ± 11.3, LHBS: 99.1 ± 11.5; EFS: 19.7 ± 4.8). Severe Popeye deformities (measured by LHBS) were found in 6% of the cases, however if they occurred patients (13.4 ± 3.8) evaluated them as significantly less disadvantageous than the examiners (11.9 ± 4.7). There were no neurovascular injuries, infections or fractures., Conclusion: STLHB-IC is a safe, reproducible technique with convincing functional and cosmetic results that provides high patient satisfaction.

In arthroscopic remplissage, surgeons may inadvertently pass sutures through the teres minor rather than the infraspinatus tendon. This misplacement of the sutures may lead to poor outcomes. The authors describe the novel use of the posterior band of the inferior glenohumeral ligament, known as the "wave sign," as a reliable intra-articular landmark for suture anchor placement to improve suture passage accuracy. Twelve cadaveric shoulders underwent arthroscopic remplissage by a fellowship-trained surgeon. During the first phase of the study, remplissage was performed on 6 specimens with standard technique. The intra-articular wave sign was visualized on all specimens. Specimens were dissected to the level of the joint, and the location of each suture anchor and suture pass was noted. Using the results from the first set of specimens, the surgeon performed remplissage in the second set of 6 specimens using specific measurements from intra-articular landmarks. On dissection of the initial 6 specimens, 75% of sutures were passed through the infraspinatus and 25% were passed through the teres minor. For the remaining 6 specimens, care was taken to place 1 suture anchor at the superior edge of the wave sign and 1 suture anchor 1 cm superior to the wave sign. When suture anchors were successfully passed above the superior tip of the wave sign, the likelihood of infraspinatus tendon penetration was 17 times greater. Placement of the suture anchors at or above the superior tip of the intra-articular wave sign most reliably produced capsulotenodesis of the infraspinatus muscle. [Orthopedics. 2017; 40(5):e831-e835.]., (Copyright 2017, SLACK Incorporated.)

Proximal humerus fracture after pectoralis major tendon repair has been recently reported. Although this complication is rare, it may be possible to decrease such risk using newer techniques for myotenodesis. This study was designed to evaluate various unicortical stress risers created at the proximal humeral metadiaphysis during myotenodesis for repair of pectoralis major ruptures. A simulated pectoralis major myotenodesis was performed using fourth-generation Sawbones (N=30). Using previously described anatomic landmarks for the tendinous insertion, 3 repair techniques were compared: bone trough, tenodesis screws, and suture anchors (N=10 each). Combined compression and torsional load was sequentially increased until failure. Linear and rotational displacement data were collected. The average number of cycles before reaching terminal failure was 383 for the bone trough group, 658 for the tenodesis group, and 832 for the suture anchor group. Both the tenodesis and the suture anchor groups were significantly more resistant to fracture than the bone trough group (P<.001). The suture anchor group was significantly more resistant to fracture than the tenodesis group (P<.001). All test constructs failed in rotational stability, producing spiral fractures, which incorporated the unicortical defects in all cases. When tested under physiologic parameters of axial compression and torsion, failure occurred from rotational force, producing spiral fractures, which incorporated the unicortical stress risers in all cases. The intramedullary suture anchor configuration proved to be the most stable construct under combined axial and torsional loading. Using a bone trough technique for proximal humerus myotenodesis may increase postoperative fracture risk. [Orthopedics. 2017; 40(5):e801-e805.]., (Copyright 2017, SLACK Incorporated.)

Closed tendon ruptures of the thumb that require secondary reconstruction can affect the extensor pollicis longus (EPL), extensor pollicis brevis (EPB) and flexor pollicis longus (FPL) tendons. Treatment of rupture of the EPB tendon consists of refixation to the bone and temporary transfixation of the joint. In the case of preexisting or posttraumatic arthrosis, definitive arthrodesis of the thumb is the best procedure. Closed ruptures of the EPL and FPL tendons at the wrist joint cannot be treated by direct tendon suture. Rupture of the EPL tendon occurs after distal radius fractures either due to protruding screws or following conservative treatment especially in undisplaced fractures. Transfer of the extensor indicis tendon to the distal EPL stump is a good option and free interposition of the palmaris longus tendon is a possible alternative. The tension should be adjusted to slight overcorrection, which can be checked intraoperatively by performing the tenodesis test. Closed FPL ruptures at the wrist typically occur 3-6 months after osteosynthesis of distal radius fractures with palmar plates and are mostly characterized by crepitation and pain lasting for several weeks. They can be prevented by premature plate removal, synovectomy and carpal tunnel release. For treatment of a ruptured FPL tendon in adult patients the options for tendon reconstruction should be weighed up against the less complicated tenodesis or arthrodesis of the thumb interphalangeal joint.

Objective: To restore the physiologic anterior and posterior capsular volume to achieve an anatomic central contact point of the glenohumeral articulation and treatment of concomitant glenohumeral injuries due to posterosuperior impingement (PSI)., Indications: Plateauing of clinical improvement despite adequate nonsurgical treatment (for at least 6-12 months)., Contraindications: General contraindications for elective arthroscopic surgery., Surgical Technique: Diagnostic arthroscopy of the glenohumeral joint through the posterior portal to assess stability of the biceps-labral complex even in the Abduction and External Rotation (ABER) position to confirm the diagnosis of PSI and to detect concomitant glenohumeral injuries. In most cases posterosuperior SLAP (superior labrum anterior posterior) repair or tenodesis of the long head of the biceps., Postoperative Management: Arm sling for 6 weeks with limited range of motion. Free active range of motion of elbow and wrist. Limited shoulder external rotation for 6 weeks. Free shoulder range of motion from week 7, full daily life activities after 12 weeks. Modification of the postoperative management according to intraoperative findings., Results: At our hospital 18 overhead athletes (6 women, 12 men, mean age 31 years) with PSI without SLAP lesion or rotator cuff tear underwent isolated plication of the anteroinferior capsule after primary nonsurgical treatment. At a mean period of 9 months, 16 patients returned to their pre-injury sports activity level, 2 patients had to give up their sports due to persisting shoulder problems. At a mean follow-up of 27 months (range 12-55 months) the Walch Duplay score was on average 82.9 ± 8.3 for men and 73.8 ± 5.9 for women.

Objective: Therapy of intraarticular lesions and elimination of structural risk factors for those suffering from clinical manifest anterosuperiorer impingement (ASI) of the shoulder. This includes as a maximum version the arthroscopic repair of supraspinatus (SST) and subscapularis tendon (SCT) tears with subsequent subpectoral tenodesis of the long head of the biceps tendon (LBT) and arthroscopic coracoplasty., Indications: Clinical manifest anterosuperiorer impingement of the shoulder with anterior shoulder pain, failed conservative treatment and clear intraarticular damage in radiological imaging. This involves in detail lesions of the SST, SCT and damage to the LBT., Contraindications: Lack of structural intraarticular lesions or massive osteoarthritis. Persistent dysfunction of active and passive glenohumeral and scapulathoracal motion, due to neurologic deficits or stiff shoulder. A hypertrophic or deformed healed coracoid process is seen as a structural risk factor for suffering from ASI and should be addressed surgically when causing impingement., Surgical Technique: Arthroscopic tenotomy of the LBT with subsequent repair of the SST and SCT. Arthroscopic coracoplasty if indicated and subpectoral tenodesis of the long head of the biceps., Postoperative Management: No biceps activity and intermittent immobilization in sling for 6 weeks. Limitation of abduction, flexion and external rotation for 6 weeks depending on rotator cuff tendon repair. Start of sport-specific training after 3 months, over-head sports 6 months postoperatively., Results: The arthroscopic repair of anterosuperior rotator cuff tears provides reliable results for improvement in function, decreases in pain and improvement in shoulder scores. The overall rate of adverse events is low.

Purpose: One of the options to repair a ruptured distal biceps tendon to the radial tuberosity is by means of a transosseous cortical button. Although excellent functional outcomes have been reported, no studies have been performed to quantify the effect of the transosseous fixation technique on the radius. Our study evaluated the clinical outcome and radiological outcome of this technique. The main goal of this study was to evaluate the radiographic evolution of the bone tunnel in the radius., Methods: Patients with an acute distal biceps tendon rupture treated with a transosseous cortical button were invited to take part in the study. Fourteen patients were included in the final analysis. All patients were evaluated both clinically and by computed tomography scanning of the proximal radius after a minimum follow-up of 2 years. Outcomes were recorded using the visual analog scale score for pain, the Mayo Elbow Performance Score, and Disabilities of the Arm, Shoulder, and Hand scores. Bone tunnel volume was measured with semiautomated computed tomography segmentation using image-processing software., Results: There were no failures of fixation in the patient group examined. Elbow mobility, arm, and forearm circumference were symmetric for all patients. Average visual analog scale for pain was less than 2. Mean Disabilities of the Arm, Shoulder, and Hand score and Mayo Elbow Performance Score were 2.3 and 97.6, respectively. Computed tomography images showed an average closure of the radial bony tunnel of 64% of the initial volume., Conclusions: Biceps tendon repair with cortical button fixation only shows partial tunnel closure. This could reduce the risk of potential complications due to osteolysis, such as radius fracture or hardware failure. Functional results were excellent and comparable to other fixation methods. The role of interference screws in transosseous cortical button techniques to strengthen the repair and to avoid osteolysis may therefore be questioned., Type of Study/level of Evidence: Therapeutic IV., (Copyright © 2016 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Distal biceps tendon (DBT) ruptures are infrequent injuries that result in pain, weakness, and cosmetic deformity. Severe retraction of the ruptured DBT can occur at the time of injury, or in chronic neglected ruptures, and surgical exposure is performed using a single incision or a 2-incision technique. The technique presented here describes an endoscopic approach using 3 portals that provide access to the retracted DBT, biceps sheath, and radial tuberosity. Preoperative sonographic localization of the retracted DBT and neurovascular structures is used to guide portal placement. The parabiceps portal is used for visualization of the biceps sheath remnant, and the midbiceps portal is used to visualize and retrieve the retracted tendon in the arm. The retracted DBT is shuttled through the biceps sheath into the upper forearm, and 2 suture anchors are passed into the radial tuberosity under direct endoscopic vision. The DBT is whipstitched via the distal anterior portal, and nonsliding knots are tied to securely reattach the DBT to the prepared radial tuberosity., (Copyright © 2016 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: To assess the maximum and end torque of a fourth-generation composite humerus model with no screw inserted or with a screw inserted in the distal (subpectoral) position or proximal (suprapectoral) position., Methods: 24 large-size, fourth-generation composite humeri were randomised to the control (n=8), proximal (n=8), or distal (n=8) group. For the latter 2 groups, an 8-mm-head interference screw (7x25 mm) was inserted at 1 cm proximal and 1 cm distal to the superior aspect of the insertion of the pectoralis major tendon, respectively. The maximum and end torque of each humerus was assessed., Results: Respectively for the control, proximal, and distal groups, the maximum torque was 81.8, 78.7, and 74.3 Nm, and the end torque was 80.7, 78.6, and 71.8 Nm; only the difference between control and distal groups was significant (p=0.005 for maximum torque and p=0.033 for end torque). All fractures in both control and proximal groups involved the distal 1/3 humerus. In the distal group, the fractures involved either the distal 1/3 humerus (n=6) or the screw-hole (n=2); the difference between the 2 types of fracture was not significant in terms of maximum torque (75.7 vs. 70.0, p=0.086) or end torque (75.3 vs. 61.4, p=0.40)., Conclusion: Compared with proximal placement of an interference screw, distal placement decreased the maximum torque (though not significantly) and may increase the risk of proximal humeral fracture.

Purpose: To compare the biomechanical characteristics of the subpectoral Y-knot all-suture anchor fixation with those of the interference screw technique., Methods: Sixteen fresh-frozen human cadaveric shoulders with a mean age of 67.6 ± 5.8 years (range, 52 to 74 years) were studied. The specimens were randomly grouped into 2 experimental biceps tenodesis groups (n = 8): Y-knot all-suture anchor or interference screw. The specimens were cyclically tested to failure by applying tensile forces parallel to the longitudinal axis of the humerus. A preload of 5 N was applied for 2 minutes prior to cyclic loading for 500 cycles from 5 to 70 N at 1 Hz; subsequently, a load-to-failure test at 1 mm/s was performed. The ultimate failure load, stiffness, displacement at cyclic and failure loading, and mode of failure were recorded., Results: The all-suture anchor technique displayed values of ultimate failure load and stiffness comparable to that of the interference screw technique. The displacement at cyclic and failure loading of the all-suture anchor trials were significantly greater than the interference screw (P = .0002). The all-suture anchor specimens experienced anchor pullout and tendon tear equally during the trials, whereas the interference screw group experienced tendon tear in most of the cases and screw pullout in 2 trials., Conclusions: The Y-knot all-suture anchor fixation provides equivalent ultimate failure load and stiffness when compared with the interference screw technique in tenodesis of the proximal biceps tendon from a subpectoral approach. However, the interference screw technique demonstrates significantly less displacement in response to cyclic and failure loading., Clinical Relevance: The all-suture anchor fixation is an alternative technique for subpectoral biceps tenodesis even at greater displacement when compared with the interference screw fixation during cyclic and failure loading., (Copyright © 2016 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

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.

Synchronous quadriceps tendon rupture is rare. A 29-year-old man, an amateur weight lifter, taking androgenic-anabolic steroids (AAS), developed sudden onset bilateral pain and swelling of his anterior thighs when attempting to squat 280 kg (620 lb). Examination revealed gross swelling superior to the patella and palpable gaps in both quadriceps tendons. He underwent successful operative repair. MRI revealed a partial tear of the anterior cruciate ligament (ACL) of the right knee. This was not reconstructed. Only a few case reports of the association between AAS and quadriceps rupture exist in the literature, with none to the best of our knowledge in the past 10 years. ACL rupture coexisting is very rare, with only two reported cases., (2016 BMJ Publishing Group Ltd.)

Background: Although reconstruction methods have improved, tendon retears remain a major complication associated with rotator cuff repair. With the application of patches, either by interposition or by augmentation, surgeons can attempt to close an irreparable cuff defect or improve the mechanical and biological properties of tendons respectively., Objectives: Which factors need to be considered when using a patch and what outcome can be expected?, Materials and Methods: Based on the current literature, an overview of the techniques and materials in use and biomechanical and clinical experience is provided., Results: The literature shows clear improvements in the biomechanical properties of a repair with patch augmentation; in particular, weakened tendons of the anterior supraspinatus and superior infraspinatus benefit most. It is important to keep in mind that each patch material has its own individual properties, which makes comparison of the various patch types difficult. The current scientific evidence is promising, although larger level 1 studies are still required., Conclusions: The general use of patches cannot be recommended at this time. Nevertheless, the use of a patch should be considered in patients who are at a high risk of recurrent retears. In future, patches will probably be applied mainly as part of a combined effort, together with biological measures to further reduce retear rates.

Background: Humeral fracture following subpectoral biceps tenodesis has been previously reported; however, there are no published biomechanical studies reporting the resulting torsional strength of the humerus. Our purpose was to determine if there is an increased risk of humerus fracture after subpectoral biceps tenodesis with an interference screw and to determine if screw size is also a factor. We hypothesized that limbs receiving the procedure would have reduced failure torque and rotation under external rotation compared to untreated controls and that the larger screw size would result in inferior mechanical properties compared to the smaller., Methods: Twenty matched pairs of embalmed cadaveric humeri were subjected to subpectoral biceps tenodesis using either a 6.25 or 8.0mm interference screw, with the untreated contralateral limb serving as a control. Each humerus was mechanically tested in torsional external rotation to failure., Findings: Maximum torque and rotation to failure were reduced in the tenodesis group compared to controls; however, there was no difference between screw sizes. When both screw sizes were combined into a single group, paired t-tests also showed similar differences., Interpretation: Based on our experiment, there is an increased risk for humerus spiral fracture when subjected to torsional external rotation after subpectoral biceps tenodesis with an interference screw compared to an intact humerus; however, there is not a significant difference between a 6.25mm and 8.0mm screw. Surgeons may elect to use alternative fixation methods in patients at high risk (e.g., overhead throwing athletes, etc.) for torsional loads and fracture., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: Instability of the sternoclavicular joint is a very uncommon disorder of the shoulder girdle. Acute traumatic dislocations are commonly treated nonoperatively. But severe displacement or chronic instability with recurrent symptomatic subluxation may require surgical intervention. We present our results with open reduction and internal fixation through an autologous gracilis tendon transplant or fiber tape in 8 patients treated surgically. The operative stabilisation of the sternoclavicular joint reduces pain level and improves function of the shoulder. This technique provides an effective surgical procedure for treatment of symptomatic sternoclavicular joint instability., Objective: Restoration of the function and aspect of the sternoclavicular joint., Indications: Chronic and painful instabilities., Contraindications: Local infection, tumor., Surgical Technique: The gracilis tendon graft is harvested as previously described by Petersen. Direct incision over the sternoclavicular joint. Sharp dissection of the periostal sleeve and partial release of sternocleidomastoideus and pextoralis muscle. Resection of osteophytes. Careful placement of a raspatorium under the proximal clavicle and sternum to protect the mediastinal structures. Application of 2.5 or 3.2 mm drill holes to the sternum and the proximal clavicle. The gracilis tendon or the fiber tape is pulled through the drill holes in a figure of eight and then sutured. Recontruction of the joint capsule, closure of the wound., Postoperative Management: Gilchrist brace for 3-5 days, functional physiotherapy with a maximum abduction of 90° for 6 weeks. No carrying or lifting of weights greater than 5 kg for 3 months., Results: During the period from January 2006 to December 2010, 8 patients with sternoclavicular instability were treated. Four patients were treated with fiber tape and four were treated with a gracilis tendon autograft. Postoperative all patients described a reduction of pain and improved shoulder function. The Constant score was 72 points, the DASH 58 points.

Background: This study aimed to evaluate the differences in biomechanical properties of biceps tenodesis when performed with sheathed versus unsheathed screws and also to investigate the effect of altering the pre-tension., Methods: Tenodesis was performed in an in vitro model using biomechanical test blocks and ovine tendons. Blocks were allocated to 1 of 5 groups which varied by method of tenodesis and cyclical loading protocol: Group A, Biosure PK screw (10-100 N), Group B: 7-8 mm Biosure Sync and Biosure PK screw (10-100 N), Group C: Biosure PK screw (10-70 N), Group D: Biosure PK (20-100 N), and Group E: custom sheath and Biosure PK screw (10-100 N). If tenodeses remained intact after 500 cycles maximum load to failure testing was performed., Findings: 30% of tenodeses in Group A failed prior to 500 cycles whereas none failed in the sheathed device groups (P=0.02). Using a sheathed device prevented mal-rotation. However, tenodeses in Group B were more likely to fail immediately distal to the tenodesis at a load below the anticipated maximum load to failure suggesting tendon damage during fixation. Using the custom sheath, which did not have sharp edges, resulted in a statistically significant increased maximum load to failure in Group E (348 N) when compared to Group A (228 N, mean difference 120 N, P=0.01) and Group B (253N, mean difference 95 N, P=0.0007)., Interpretation: Sheathed devices prevent mal-rotation and increase stiffness and maximum load to failure. This is further improved by reducing tendon damage at the time of tenodesis., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

We describe a new technique for the reconstruction of chronic lesions of the collateral ligaments of the metacarpophalangeal ligaments of the thumb, using a Bio-Tenodesis screw for the fixation of a tendon graft in a triangular manner with proximal apex and allowing early mobilization, starting 2 weeks after operation. Short-term results after 12 to 43 months (mean, 26 mo), showed no significant differences in grip and pinch strength compared with the opposite thumb and restricted loss of motion in the metacarpophalangeal joints (10%) and the interphalangeal joints (4%). We conclude that this technique minimizes the rehabilitation and sick leave period and represents a good alternative to other methods.

Background: The use of cortical suspensory fixation in conjunction with an interference screw to treat distal biceps ruptures has yielded favorable results. However, literature examining the incidence of fixation failure in a large consecutive series of patients treated with this technique is lacking., Methods: A retrospective review of electronic medical records identified 170 distal biceps ruptures in 168 consecutive patients (164 men and 4 women) treated using a cortical button in conjunction with an interference screw. The study group was an average age of 48 years (range, 20-71 years). Records were reviewed from the time of the initial clinic visit to the most recent follow-up. Early failures were defined as those that occurred within 12 weeks of the index procedure. Failed repair was defined as tendon defect, deformity, or significant weakness in supination., Results: The early incidence of failure was 1.2%, with 2 of the fixations meeting the criteria for failure. One patient had significant brachial artery thrombosis. Other complications included posterior interosseous nerve palsy, lateral antebrachial cutaneous nerve-related complication, and numbness about the radial nerve., Conclusion: The use of a cortical suspensory fixation device in conjunction with an interference screw is an effective method of repairing a distal biceps rupture, with a low early rate of failure., (Copyright © 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

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: The purpose of this study was to assess the biomechanical performance of the long head of the biceps tenodesis with an interference screw with respect to screw depth., Methods: Twenty-one human cadaveric shoulders were randomized into 3 treatment groups (7 each): interference screw placed flush to the humeral cortex, 50% proud, or fully recessed. Bone density was determined, and subpectoral biceps tenodesis was performed with 8 × 12 mm Bio-Tenodesis screws (Arthrex, Naples, FL). Each construct was cyclically loaded from 5 to 70 N for 500 cycles at 1 Hz and then pulled to failure at 1 mm/s. Relative actuator displacement was calculated from cyclic testing. Maximum load, elongation, linear stiffness, and failure mode were recorded from pull-to-failure testing. Because of numerous failures during cyclic testing, the final load data from the fully recessed group were not statistically analyzed. The remaining groups were compared by use of a 2-tailed, Student unpaired t test and χ(2) analysis., Results: There was no significant difference in displacement among groups during cyclic testing. Five specimens in the recessed group failed during cyclic testing, whereas 2 specimens and 0 specimens failed in the proud and flush groups, respectively. The maximum loads sustained were 281.6 ± 77.8 N, 184.5 ± 56.3 N, and 209.1 ± 57.0 N for the flush group, 50% proud group, and recessed group (in those specimens surviving cyclical loading), respectively., Conclusions: Placement of a Bio-Tenodesis screw flush to the humeral cortex is preferred for maximum fixation strength in subpectoral biceps tenodesis. A screw placed to 50% depth may be effective in the laboratory setting, but recessed placement is more variable and requires additional fixation. The fully recessed group resulted in 5 of 7 failures during cyclical loading, with no specimens failing in the flush group., Clinical Relevance: This study shows the importance of determining the optimal depth of interference screw placement during biceps tenodesis to obtain optimal biomechanical performance and reduce the risk of fixation failure., (Copyright © 2014 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Various fixation techniques have been described for ruptured distal biceps tendons. The authors hypothesized that no significant differences would be found between the mean failure strength, maximum strength, and stiffness of the interference screw and hybrid technique. Fourteen fresh-frozen human cadaveric elbows were prepared. Specimens were randomized to either interference screw or hybrid cortical button with screw fixation. The tendon was pulled at a rate of 4 mm/s until failure. Failure strength, maximum strength, and stiffness were measured and compared. Failure strength, maximum strength, and stiffness were 294±81.9 N, 294±82.1 N, and 64.4±40.5 N/mm, respectively, for the interference screw technique and 333±129 N, 383±121 N, and 56.2±40.5 N/mm, respectively, for the hybrid technique. No statistically significant difference existed between the screw and hybrid technique in failure strength, maximum strength, or stiffness (P>.05). The interference screws primarily failed by pullout of the screw and tendon, whereas in the hybrid technique, failure occurred with screw pullout followed by tearing of the biceps tendon. The results suggest that this hybrid technique is nearly as strong and stiff as the interference screw alone. Although the hybrid technique facilitates tensioning of the reconstructed tendon, the addition of the cortical button did not significantly improve the failure strength of the interference screw alone., (Copyright 2013, SLACK Incorporated.)

Background: Subpectoral biceps tenodesis has been reliably used to treat a variety of biceps tendon pathologies. Interference screws have been shown to have superior biomechanical properties compared to suture anchors; although, only single anchor constructs have been evaluated in the subpectoral region. The purpose of this study was to compare interference screw fixation with a suture anchor construct, using 2 anchors for a subpectoral tenodesis., Methods: A subpectoral biceps tenodesis was performed using either an interference screw (8 × 12 mm; Arthrex) or 2 suture anchors (Mitek G4) with #2 FiberWire (Arthrex) in a Krackow and Bunnell configuration in seven pairs of human cadavers. The humerus was inverted in an Instron and the biceps tendon was loaded vertically. Displacement driven cyclic loading was performed followed by failure loading., Results: Suture anchor constructs had lower stiffness upon initial loading (P = .013). After 100 cycles, the stiffness of the suture anchor construct "softened" (decreased 9%, P < .001), whereas the screw construct was unchanged (0.4%, P = .078). Suture anchors had significantly higher ultimate failure strain than the screws (P = .003), but ultimate failure loads were similar between constructs: 280 ± 95 N (screw) vs 310 ± 91 N (anchors) (P = .438)., Conclusion: The interference screw was significantly stiffer than the suture anchor construct. Ultimate failure loads were similar between constructs, unlike previous reports indicating interference screws had higher ultimate failure loads compared to suture anchors. Neither construct was superior with regards to stress; although, suture anchors could withstand greater elongation prior to failure., (Copyright © 2013 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.)