Single Incision Modified Tension Slide Technique in Distal Biceps Repair: Improved Load to Failure While Reducing Surgical Pitfalls.

Historically, distal biceps tendon repair through the tension slide technique (TST) using a cortical button has yielded the strongest published repair measured by observed gap formation in both cyclic and maximal load to failure. The modified tension slide technique (MTST) was developed in order to provide the surgeon with a technically simpler and biomechanically more effective way to reduce gap formation and consistently seat/bottom-out the tendon within the bone tunnel through a more direct line of pull. In order to compare the biomechanics of the MTST to the TST, we used 24 matched bovine extensor tendons, and conducted maximal load to failure and cyclical load to failure testing using an Instron 5566 machine. The mean maximal load to failure for the MTST was 444 N versus 229 N for the TST ( P <0.004) while no gap formation was observed in either group after cyclic load testing. These findings indicate that the MTST has a statistically significant increased load to gap formation of ∼2-fold in comparison to TST. In the MTST both limbs of suture are passed back through the tendon, before button implantation, eliminating the "operating in a hole" effect required in the TST, and making for a simpler surgical procedure.

The Relationships Between Surface Measurements and Underlying Tendon Autograft Length for Upper Extremity Reconstructive Surgery.

PURPOSE: The availability of tendon grafts is an important consideration for successful upper extremity reconstructive surgery, including flexor or extensor tendon reconstructions, tendon transfers, and ligament reconstructions. Graft selection is based on availability, expendability, ease of harvest, and length. Given variations in patient height and extremity length, existing average values may provide suboptimal insight into actual tendon lengths available. The purpose of this study is, therefore, to pursue a method of estimating available donor tendon lengths based on easily measured anatomical surface landmarks. METHODS: Thirty cadaveric upper and lower extremity limbs were dissected and the length of commonly harvested tendon grafts including the palmaris longus, extensor indicis proprius, extensor digiti minimi, plantaris, and second long toe extensor was measured. Surface forearm length (from finger tip to cubital fossa) and surface fibular length (from lateral malleolus to fibular head) were also measured. Correlations between surface measurements and underlying tendon lengths were analyzed, and linear models were generated that predicted tendon length as a function of surface measurements. RESULTS: Surface measurements were correlated with underlying tendon length (R = 0.46 - 0.66). Linear models could predict tendon lengths based on surface measurements. A ratio of donor tendon length compared with the limb segment measured was established for each tendon and can be applied to estimate donor tendon length. For the upper extremity tendons, the multipliers for the palmaris longus, extensor indicis proprius, and extensor digiti minimi were 0.51, 0.20, and 0.18, respectively. Lower extremity tendon ratios for the plantaris and extensor digitorum longus were 0.69 and 0.60, respectively. CONCLUSIONS: Although length of available donor tendon can be a limiting variable at the time of surgery, surgeons may be better able to estimate underlying tendon lengths using easily obtained superficial measurements. CLINICAL RELEVANCE: Information obtained from these cadaveric measurements may aid in preoperative planning in hand and upper extremity surgery.

Carpal tunnel syndrome diagnosis and treatment: a survey of members of the American Society For Surgery of the Hand.

PURPOSE: In 2007 and 2009, the American Academy of Orthopaedic Surgeons released Clinical Practice Guidelines (CPG) for diagnosis and treatment of carpal tunnel syndrome (CTS) based upon review of the literature. The lack of consistently high-level evidence resulted in several recommendations, some strongly supported, some weakly supported, and others controversial. We postulated that a survey of American Society for Surgery of the Hand (ASSH) members would provide insight into practice patterns among hand surgeons treating CTS and demonstrate the extent to which the CPG influenced practice behavior. METHODS: A multiple-choice questionnaire including detailed commonly observed clinical scenarios was developed, pre-tested, and approved by our institutional review board and the ASSH Web site committee chair. An anonymous electronic survey was emailed to ASSH members. RESULTS: Surveys were sent to 2,650 eligible ASSH members, and 27% responded. Seventy-two percent would advise a patient to have carpal tunnel release (CTR) if the patient had both classic history/examination of CTS and complete relief following cortisone injection. Forty-seven percent responded that in this scenario electrodiagnostic testing (EDX) is rarely or never necessary to recommend CTR. Seventy-nine percent of respondents were at least slightly more likely to order EDX based on CPG recommendations. Of these respondents, 57% replied that this was because of potential medicolegal ramifications. CONCLUSIONS: Although the CPG recommended EDX before surgery, and although most responding ASSH members use EDX to advise CTR, a majority answered that a supporting history and physical examination alone can be sufficient to recommend surgery, that a positive response to a cortisone injection can be sufficient indication for CTR, that EDX is not necessary in all cases of CTS, and that they would perform CTR in face of normal EDX if cortisone temporarily resolved symptoms. Among respondents more likely to order EDX based on the CPG, 57% answered that it was in some circumstances due to potential medicolegal ramifications. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic and decision analysis III.