Painful Entrapment of the Lateral Antebrachial Cutaneous Nerve After Distal Biceps Repair: A Case Report.

CASE: A 46-year-old man presented with continued pain after distal biceps repair. On revision surgery, he was found to have entrapment of the lateral antebrachial cutaneous nerve (LABCN). After nerve transection, relocation to its native course, and subsequent repair, the patient experienced complete resolution of his preoperative symptomatology. CONCLUSION: To the author's knowledge, the current study is the first to describe symptomatic entrapment of the LABCN after distal biceps repair with a satisfying outcome after nerve transection, relocation, and repair.

The utility of the biceps palpation-rotation test in diagnosing partial distal biceps tendon tears.

BACKGROUND: Partial tears of the distal biceps tendon can be difficult to diagnose based on clinical examination and magnetic resonance imaging (MRI). METHODS: Patients from a single surgeon's practice from 2000 to 2018 with a partial distal biceps tendon tear were retrospectively reviewed to determine the utility of the distal biceps palpation-rotation test in the detection of partial tears. This test is performed by palpating the bicipital tuberosity at the lateral forearm while ranging the forearm from supination to pronation with the arm adducted at the patient's side and the elbow flexed to 90°. A positive test elicits tenderness at the tuberosity with the arm in pronation but not in supination. Examination findings were correlated with MRI reports confirming a partial tear. Twelve cadaveric arms were dissected to determine overall pronosupination range of motion, the degree of pronation at which the bicipital tuberosity is maximally palpable, and anatomic measurements of the bicipital tuberosity to guide the optimal technique when carrying out the maneuver. RESULTS: Ninety-nine patients were diagnosed with a partial distal biceps tendon, of whom 34 had available MRI reports and complete physical examination documentation. Thirty-three of 34 patients (97%) had partial tears on MRI. The hook test was negative in all cases. All patients had tenderness with resisted supination. In those with MRI-confirmed partial tears, the palpation-rotation test was positive in all patients (100% sensitivity). The bicipital tuberosity was maximally palpated at the dorsolateral forearm at a mean 20° of pronation, and the proximal and distal boundaries of the radial tuberosity were 2.5 cm and 5.3 cm, on average, distal to the radial head, respectively. CONCLUSION: A positive palpation-rotation test was seen in 33 of 33 patients (100% sensitivity), as correlated with MRI. The combination of an intact distal biceps tendon within the antecubital fossa, tenderness on resisted supination, and a positive palpation-rotation test are highly suggestive of a partial distal biceps tendon tear.

Augmentation of Distal Biceps Tendon Ruptures With the Lacertus Fibrosus: A Biomechanical Study in a Tendon-Deficient Model.

BACKGROUND: Chronic distal biceps tendon ruptures may require tendon graft augmentation secondary to tendon attrition or retraction. The lacertus fibrosus is a local, cost-effective graft that can be used to supplement reconstruction. PURPOSE: To compare the biomechanical strength of distal biceps tendon repairs with and without lacertus fibrosus augmentation in a tendon-deficient cadaveric model. STUDY DESIGN: Controlled laboratory study. METHODS: Sixteen fresh-frozen matched cadaveric pairs of elbows were randomized into 2 groups: (1) standard distal biceps tendon repair and (2) tendon-deficient (50% step cut) repair with lacertus fibrosus augmentation. All repairs were completed using an oval bone trough and 2 double-loaded No. 2 braided nonabsorbable sutures in a locked Krackow fashion tied over a lateral bone bridge. For the lacertus augmentation group, the lacertus was wrapped circumferentially in a tubular fashion around the tendon to restore the native size and incorporated into the Krackow suture. All specimens underwent cyclic loading and then were loaded to failure. Displacement, stiffness, load to failure, and mode of failure were recorded. RESULTS: The standard repair and lacertus augmentation groups had similar displacements on cyclic loading (1.66 ± 0.62 vs 1.62 ± 0.58 mm, respectively; P = .894). The stiffness was significantly greater for the standard repair group (21.3 ± 2.5 vs 18.5 ± 3.5 N/mm; P = .044). Both groups provided excellent mean peak load to failure strengths, despite the standard repair group having significantly greater strength (462.4 ± 140.5 vs 377.3 ± 101.1 N; P = .022). The primary mode of failure in the standard repair group was fracture at the bone bridge (n = 5/8) compared with suture pullout (n = 4/8) in the lacertus augmentation group. CONCLUSION: Lacertus fibrosus augmentation of a tendon-deficient biceps repair was less stiff and had lower mean load to failure compared with repair of the native tendon in this cadaveric model, but these values remained biomechanically acceptable above critical thresholds. Consequently, lacertus fibrosus augmentation is a viable option for chronic distal biceps tendon ruptures with tendon attrition. CLINICAL RELEVANCE: Chronic distal biceps tendon ruptures may require autograft or allograft reconstruction secondary to tendon scarring, shortening, attrition, and degeneration. The lacertus fibrosus is a cost-effective and low-morbidity local autograft that can be used to augment repairs.

Distal biceps repair using the lacertus fibrosus as a local graft.

BACKGROUND: We report a case series of 15 patients who underwent a new surgical technique that uses a transfer of the lacertus fibrosus to augment the repair of the distal biceps tendon. This technique seeks to minimize the need for and potential complications associated with autogenous or allograft tendon reconstruction in this clinical scenario. METHODS: We reviewed the clinical outcomes of patients who both underwent a lacertus transfer for biceps tendon reconstruction during a 10-year period and had at least 6 months of follow-up. Their clinical outcomes, including success of tendon repair, functional performance, and associated surgical complications, were evaluated. RESULTS: During a 10-year period, 244 patients underwent surgery for repair or reconstruction of the distal biceps tendon. During this time, 15 patients met the criteria for use of the lacertus transfer technique. When direct repair was not possible because of tendon retraction and attrition, although a tendon graft was considered, the intact lacertus fibrosus was used to augment the biceps repair. Of these 15 patients, 12 met study inclusion criteria. At latest follow-up, all 12 patients were successfully treated by the lacertus transfer without complication, had regained elbow flexion and forearm supination strength, and had no lacertus harvest complications. CONCLUSIONS: When operative treatment is chosen for biceps tendon injuries and if the lacertus fibrosus is intact, transfer of the lacertus to augment repair of the distal biceps provides predictable outcomes without the potential complications associated with allograft or autograft tendon reconstruction.

Operative treatment of chronic distal biceps tendon ruptures.

Chronic biceps tendon ruptures typically involve tendon retraction, scarring, and even compromised tissue. Indirect repair, such as tenodesis to the brachialis, does not provide optimal functional recovery. Chronic biceps tendon ruptures can be reconstructed with autogenous grafts (semitendinosis, tensor fascia lata) or allografts (typically Achilles tendon). The complications associated with these grafts include harvest site morbidity and graft incorporation. Using a vascularized local soft tissue source could minimize complications of graft reconstructions. The authors provide a novel reconstructive technique, reconstruction using the lacertus fibrosis, as a local graft source for chronic distal biceps tendon ruptures.

Articular cartilage injuries of the capitellum interposed in radial head fractures: a report of ten cases.

Ten cases of Mason type I and type II isolated radial head fractures are reported, in which an unexpected cartilaginous fragment of the capitellum trapped within the radial head fracture was identified at the time of surgery. In no case was this injury pattern identified on preoperative imaging, including computed tomography in 2 cases. Five patients did have preoperative mechanical findings with forearm rotation. At surgery, all capitellar fragments were found to originate from the posterolateral capitellum. Excision of the capitellar fragment and internal fixation of the radial head fracture were performed in all cases. No sequelae were identified on short-term follow-up. This series highlights an injury pattern that should be considered in isolated nondisplaced and minimally displaced fractures of the radial head. The natural history of this finding, when treated conservatively, is unknown.

Lateral compression injuries in the pediatric elbow: Panner's disease and osteochondritis dissecans of the capitellum.

Lateral compression injuries of the elbow typically occur in throwing athletes and gymnasts. In the preadolescent and adolescent patient, these injuries predominantly include Panner's disease and osteochondritis dissecans. Panner's disease, an osteochondrosis of the capitellum, is a rare disorder that usually affects the dominant extremity in individuals younger than age 10 years. Symptomatic management of Panner's disease consisting of reduction of stressful activities of the elbow is usually sufficient to allow resolution. Although a prolonged period is required for healing, most patients demonstrate excellent long-term results. Osteochondritis dissecans of the capitellum typically occurs in adolescents and is associated with loose body formation. Panner's disease and osteochondritis dissecans likely represent a continuum of disordered endochondral ossification with presentation and prognosis dependent primarily on age at onset.