Double-incision Approach Research Articles

Safety and Efficacy of One vs Two Incision Broström Gould with Calcaneal Osteotomy and Peroneal Tendon Debridement Surgery

Surgical intervention, such as the Broström-Gould procedure, is typically indicated for patients with chronic lateral ankle instability. In this study, we are comparing the safety and efficacy of the Broström-Gould procedure with peroneal tendon debridement, a sliding lateralizing calcaneal osteotomy, and adjuvant procedures performed with a single- versus double-incision approach. Our retrospective analysis included patients who underwent the procedure of interest between 2011 and 2020. Patients were divided into 2 groups: undergoing either a 1-incision (n = 53) or a 2-incision approach (n = 47), both with a lateralizing calcaneal osteotomy. A significant difference in skin bridge breakdown was observed between the 2-incision (n = 6 [13%]) and 1-incision groups (n = 0 [0%]). There were no significant differences in infection, deep wound dehiscence, nerve palsy, or neuroma between patients in the 2 groups. Furthermore, no statistically significant differences in mean PROMIS scores existed between the cohorts. The described Broström-Gould procedure shows promise for treating chronic ankle instability. While patients in both single- and double-incision groups had similar rates of postoperative complications, the decreased incidence of skin bridge breakdown in the 1incision group highlights the approach's safety and potential benefits in reducing wound-related complications.

Treatment of the Distal Forearm Fracture by Volar Dual Window Approach.

Distal forearm fractures were defined as distal radius fractures with concomitant distal ulna fractures, except ulna styloid fractures. Distal forearm fractures are common among geriatric populations, particularly those with osteoporosis. Conventionally, distal forearm fractures are reduced by a double incision approach; however, malreduction and instability of the distal radioulnar joint were not uncommon. We introduced a modified volar dual window approach to treat the distal forearm fracture and evaluate the functional outcomes and complications. From January 2020 to June 2023, 13 patients with distal forearm fractures underwent open reduction by the modified dual window approach with locking plate fixation. After surgery, splints were applied for two weeks, and the patients underwent postoperative hand therapy for three months. The mean Quick Disabilities of the Arm, Shoulder, and Hand scores, range of motions, grip strength, postoperative radiographic parameters, and complications data were collected. The mean follow-up period was 12.1 months, and the mean age was 52.3 years. Average wrist flexion was 67°, extension 69°, pronation 81°, and supination 79°. Grip strength was 28.3 ± 11.5 kg, which was 88% of the uninjured opposite side. The Visual Analog Scale score during activities was recorded as 0.5 ± 0.9. The mean Quick Disabilities of the Arm, Shoulder, and Hand score was 14 ± 11.5. The postoperative radiographic parameters were as follows: radial height: 10.8 ± 1.7 mm, radial inclination: 22.6 ± 3.7°, volar tilting: 4.0 ± 3.9°, and ulnar variance: -0.4 ± 1.4 mm. All the patients achieved bone union at the final follow-up. Two patients underwent ulnar implant removal due to irritation symptoms. Neither infection, nor neurovascular injury, nor malreduction developed in these patients. The modified volar dual window approach can achieve good wrist function and distal forearm fracture reduction without increasing neurovascular or wound healing complications. This method is an alternative approach for distal forearm fracture, especially in comminuted distal ulna fracture or distal radioulnar joint incongruity.

Distal biceps tendon ruptures: clinical features, diagnostic strategy and treatment options

Relevance. This paper reviews the latest evidence concerning distal biceps tendon repair, particularly aspects such as tear type, patient demographics, diagnostic clues, surgical indications, the anatomy of distal tendon insertion, radial tuberosity, single- vs double-incision reconstruction, fixation techniques (bone tunnels, distal biceps button, interference screw, button plus screw) and postoperative outcomes.Material and methods. The MEDLINE, Cochrane, Web of Science, Scopus and Elibrary online databases were searched using the keywords ‘distal biceps tendon’, ‘elbow’, ‘intramedullary’, ‘partial’. ‘complete’, ‘review’ and ‘rupture’. Sixty publications on distal biceps tendon rupture treatment were identified that appeared over 60 years, between 1951 and October 2021.Results and discussion. The review has demonstrated that complete deltoid ligament (DBT) tears are predominantly diagnosed clinically, while medical imaging has proven to be a valuable adjunct for diagnosing partial tears. Advances in clinical and medical imaging of partial tears have the potential to expedite the diagnostic process and guide treatment strategies. Primary repair is commonly employed for complete tears, utilizing either a single-incision or double-incision approach, resulting in favorable clinical outcomes. However, the double-incision technique carries a higher risk of heterotopic ossification, whereas the single-incision approach presents a greater risk of nerve-related complications. To mitigate the risk of posterior interosseous nerve lesions in single-incision repairs, intramedullary fixation may serve as a viable solution. Additionally, DBT endoscopy holds promise for the treatment of low-grade partial tears and tendinosis.

Systematic review of distal biceps tendon rupture in athletes: treatment and rehabilitation.

Distal biceps tendon rupture is a rare injury associated with decreased elbow flexion and forearm supination strength. This impairment is not tolerated by high-demand patients like athletes. To review treatment and rehabilitation applied to injured athletes and study their impact in return to sports. MEDLINE, Cochrane, Web of Science, and Scopus online databases were searched. A systematic review was conducted using the PRISMA guidelines; studies published on distal biceps tendon rupture treatment and rehabilitation of athletes until June 30, 2021, were identified. A quantitative synthesis of factor related to return to preinjury sport activity was made. Ten articles were identified, including 157 athletes. Mean age was 40.5 years, and the dominant arm was injured in 103 cases (66%). Rupture was acute in 121 athletes (77%), and the mean follow-up was 25.7 months. A hundred and fifty-three athletes (97.5%) successfully returned to sport within a mean time of 6.2 months. Surgical treatment was followed in all cases. One-incision technique was chosen in 115 (73%) and suture anchor fixation in 52 (33%) cases. No postsurgical immobilization was reported in 38 (24%) and immobilization for 2 weeks in 124 (79%) athletes. Decreased supination-pronation and flexion-extension arc was found in 63 (40%) and 27 (17%) cases, respectively. Earlier return to sport was associated with nondominant-side (P=.007) and acute (P<.001) injuries, participation in weightlifting (P=.001), double-incision approach (P=.005), cortical button fixation (P<.001), and absence of supination-pronation restriction (P=.032). Time of return to sport activity was independent of rehabilitation, including immobilization (P=.539) and strengthening (P=.155), and decreased flexion-extension arc (P=.059). Athletes sustaining distal biceps tendon rupture have a high postoperative return to sport rate, independently of selected surgical technique or rehabilitation program. However, a relation between the surgical technique and time of return to sport was found. Rehabilitation did not influence time of return to sport.

A modified three-incision approach to treating three-column Lisfranc injuries

PurposeThe most popular surgical approach to manage Lisfranc fracture-dislocations is the double-incision approach, which frequently causes a variety of complications, such as skin necrosis, rotational malreduction of the first tarsometatarsal joint (TMTJ) and lateral column dorsoplantar malreduction of the TMTJ. We introduce a three-incision approach to treat Lisfranc fracture-dislocations with only minor postoperative complications and good foot function. MethodsWe prospectively selected 30 previously healthy patients, ranging from 18 to 60 years of age, but only 23 patients completed the follow-up and thus were finally included, with an average age of 38.1 ± 12.9 years. All patients have sustained Lisfranc fracture-dislocations involving all three-column; 13.0% (3/23) were Myerson classification type A (medial), 47.8% (11/23) were type A (lateral), and 39.1% (9/23) were type C2. All patients were treated via a three-incision approach: a long incision made along the lateral border of the second ray was used as a working incision to visualize and reduce the first three TMTJs, as well as to apply internal fixation instrumentation; a 2 cm medial incision was made at the medial side of the first TMTJ as an inspecting incision, ensuring good reduction of the first TMTJ in medial and plantar view; another 1 cm inspecting incision was made at the dorsal side of the fourth/fifth TMTJ to prevent sagittal subluxation of the lateral column. Mean ± SD was used for quantitative data such as operation time, follow-up time and foot function scores. Postoperative complications were documented, and foot function was evaluated using the American orthopaedic foot & ankle society score, foot function index and Maryland foot score at follow-up. The foot function of the injured foot and contralateral foot of the same patient was at the end of follow-up, and independent sample t-test was used for statistical analysis. ResultsThe median operation time was 117.9 ± 14.6 min (range 93 - 142 min). All complications occurred within three months after the operation, and included delayed wound healing (17.4%), superficial infection (8.7%), complex regional pain syndrome (4.3%) and neuroma (4.3%). There was no case of postoperative skin necrosis or malreduction. At the end of follow-up of 14.1 ± 1.2 months (range 12–16 months), the median American orthopaedic foot & ankle society score of the operated foot was 89.7 ± 5.7, the median foot function index was 21.7 ± 9.9, and the median Maryland foot score was 88.7 ± 4.8. There were no significant differences between the operated and contralateral sides, in terms of foot function, at the end of followup (p > 0.05). ConclusionThe three-incision approach can provide adequate visualization of all TMTJs to ensure anatomical reduction and offer sufficient working space to apply internal fixation instrumentation, which is effective in treating three-column Lisfranc fracture-dislocations with minor soft tissue complications and satisfactory functional recovery.

Double-Incision Technique for the Treatment of Distal Biceps Tendon Rupture.

A longitudinal antecubital incision of 3 to 4 cm allows dissection to identify and isolate the lateral antebrachial cutaneous nerve (LABCN). Supination of the forearm protects the posterior interosseus nerve, which often cannot be visualized. The distal portion of the distal biceps should be carefully identified and exposed. A high-resistance nonresorbable suture is sewn with use of a Krackow technique to whipstitch the distal 4 cm of the tendon. Alternatively, 2 sutures (4 strands) can be utilized. A curved forceps is placed in the interosseous space to identify the location for the second 4-cm incision, on the dorsal proximal forearm over the tip of the forceps with the forearm pronated. The radial tuberosity is exposed by bluntly separating the common extensor tendons, followed by transection of the supinator fibers. Two drill holes are made 5 mm apart from one another for suture passage. The tendon is passed across a loop of wire, from the anterior to the posterior incision. With the elbow at 90° of flexion and full pronation, the tendon is docked into the trough and the sutures are tied. Alternatively, the surgical repair of the distal biceps tendon rupture can be performed through a single anterior approach4. The exposure starts with a curved longitudinal antecubital incision, exploiting the interval between the brachioradialis and pronator teres with radial (lateral) retraction of the brachioradialis and medial retraction of the pronator teres. A single anterior incision allows repair through the use of various types of fixation devices, such as suture anchors, cortical buttons, and interference screws, but seems to carry an increased risk of neurological complications, especially in terms of paresthesias in the distribution of the LABCN. Nonoperative treatment might be acceptable for elderly patients with poor functional demands. The double-incision technique with bone-tunnel fixation provides good fixation strength with an expected low rate of neurological complications1. This approach offers a useful treatment option for young and active patients with physically demanding lifestyles. The double-incision technique is an effective and safe procedure to restore elbow functionality in patients with distal biceps tendon rupture. A meta-analysis1,4-16 revealed no significant differences in postoperative functional scores following procedures performed via the single-incision compared with double-incision approach. Although the differences were smaller than the minimal clinically important difference17, the single-incision technique yielded significantly greater flexion (mean ± standard deviation, 136° ± 13°) and pronation range of motion (79° ± 10°) compared with the double-incision technique (133° ± 13° and 75° ± 14°, respectively) at 2 years postoperatively. No differences in extension and supination were observed. Rates of heterotopic ossification ranged from 0.5% to 11% for the single-incision approach and from 1% to 21.4% for the double-incision approach, with significant differences favoring the single-incision technique, although in the majority of cases the heterotopic ossification was an incidental finding. Neurological complications were found in 24.5% and 13.4% cases for the single- and double-incision techniques, respectively, with a significant difference favoring the double-incision technique. When damage to specific nerves was evaluated, the double-incision technique was associated with significantly less risk of LABCN damage. One or 2 high-resistance nonresorbable sutures are sewn with use of a Krackow technique to whipstitch the distal 4 cm of the biceps tendon.A curved forceps is placed in the interosseous space to identify the location for the second incision, on the dorsal proximal forearm over the tip of the forceps.Pronation of the forearm protects the posterior interosseus nerve, which often cannot be visualized during volar dissection and bone fixation.Positioning the tendon more posteriorly on the radial tuberosity allows for optimal biomechanical function. ROM = range of motionCR = conventional radiologyMRI = magnetic resonance imagingUS = ultrasoundLABC = lateral antebrachial cutaneousPIN = posterior interosseous nerveHO = heterotopic ossificationCI = confidence intervalSI = single incisionDI = double incision.

Distal biceps tendon repair: cost analysis of single- versus double-incision techniques in an ambulatory surgery center

The purpose of this study was to compare the cost differences for single- versus double-incision distal biceps repair at an ambulatory surgery center (ASC) given that similar clinical outcomes have been reported between these methods. A retrospective review of financial and medical records was completed for patients who underwent distal biceps tendon repair over a three-year period at a single private orthopedic practice. Variables analyzed include the cost to the ASC of operative time and the cost of differential surgical supplies, specifically implants and disposable supplies. A total of 10 surgeons performed 104 repairs. Nine surgeons performed repairs through a single incision with use of cortical button or suture anchor fixation, and one surgeon performed transosseous suture fixation through a double-incision approach. The median tourniquet time and procedure length were 31 (interquartile range [IQR] 27-40) and 44 (IQR 39-54) minutes for single-incision repairs and 68 minutes (IQR 61-75) and 110 minutes (IQR 103-113) for double-incision repairs which were significantly different across groups (P < .001, P < .001). The total surgical cost (operative time, implants, and disposables) for single-incision repairs was a median of $758 (IQR 732-803) compared with $606 (IQR 567-629) for double-incision repairs (P < .001). However, the procedure cost with implants (not including disposables) was not significantly different for single- (median [Mdn]= $500 [IQR 475-552]) and double-incision repairs (Mdn $552 [IQR 514-564]) (P= .14) although the procedure cost with disposables (not including implant costs) favored single-incision repairs (Mdn= $478 [IQR 452-523]) over double-incision repairs (Mdn= $606 [IQR 567-629]) (P < .001). In a single surgery center, single-incision distal biceps repairs utilizing an implant were performed more expeditiously than double-incision repairs with a transosseous technique but incurred greater surgical costs. Differences in surgical time cost between the two approaches could be consequential for ASCs and other stakeholders.

Acute complete and partial distal biceps tendon ruptures: what have we learned? A review.

Acute distal biceps tendon (DBT) pathology includes bicipitoradial bursitis, tendinosis, partial and complete tears.Diagnosis of complete DBT tears is mainly clinical, whereas in partial tears medical imaging is a valuable addition to the clinical diagnosis.New insights in clinical and medical imaging of partial tears may reduce time to diagnosis and may guide the treatment plan.Most complete tears are best treated with primary repair using either a single-incision or double-incision approach with good clinical outcome.The double-incision technique has a higher risk of heterotopic ossification, whereas a single-incision technique carries a higher risk of nerve-related complications.Intramedullary fixation may be a viable solution to negate the risk of posterior interosseus nerve lesions in single-incision repairs.DBT endoscopy can be used to treat low-grade partial tears and tendinosis. Cite this article: EFORT Open Rev 2021;6:956-965. DOI: 10.1302/2058-5241.6.200145

Operative Versus Nonoperative Management for Distal Biceps Brachii Tendon Lesions: A Systematic Review and Meta-analysis.

Background:Both nonoperative and operative treatments have been proposed to manage distal biceps brachii tendon avulsions. However, the advantages and disadvantages of these approaches have not been properly quantified.Purpose:To summarize the current literature on both nonoperative and operative approaches for distal biceps brachii tendon ruptures and to quantify results and limitations. The advantages and disadvantages of the different surgical strategies were investigated as well.Study Design:Systematic review; Level of evidence, 4.Methods:A systematic literature search was performed in March 2020 using PubMed Central, Web of Science, Cochrane Library, MEDLINE, Iscrctn.com, clinicaltrials.gov, greylit.org, opengrey.eu, and Scopus literature databases. All human studies evaluating the clinical outcome of nonoperative treatment as well as different surgical techniques were included. The influence of the treatment approach was assessed in terms of the Disabilities of the Arm, Shoulder and Hand (DASH) score and the Mayo Elbow Performance Index; extension, flexion, supination, and pronation range of motion (ROM); and flexion and supination strength ratio between the injured and uninjured arms. Risk of bias and quality of evidence were assessed using the Cochrane guidelines.Results:Of 1275 studies, 53 studies (N = 1380 patients) matched the inclusion criteria. The results of the meta-analysis comparing operative versus nonoperative approaches for distal biceps tendon avulsion showed significant differences in favor of surgery in terms of DASH score (P = .02), Mayo Elbow Performance Index (P < .001), flexion strength (94.7% vs 83.0%, respectively; P < .001), and supination strength (89.2% vs 62.6%, respectively; P < .001). The surgical approach presented 10% heterotopic ossifications, 10% transient sensory nerve injuries, 1.6% transient motor nerve injuries, and a 0.1% rate of persistent motorial disorders. Comparison of the different surgical techniques showed similar results for the fixation methods, whereas the single-incision technique led to a better pronation ROM versus the double-incision approach (81.5° vs 76.1°, respectively; P = .01).Conclusion:The results of this meta-analysis showed the superiority of surgical management over the nonoperative approach for distal biceps tendon detachment, with superior flexion and supination strength and better patient-reported outcomes. The single-incision surgical approach demonstrated a slightly better pronation ROM compared with the double-incision approach, whereas all fixation methods led to similar outcomes.

Basal joint arthroplasty and carpal tunnel release comparing a single versus double incision: a prospective randomized study.

Basal thumb joint osteoarthritis frequently coexists with carpal tunnel syndrome. The two conditions have traditionally been treated surgically through separate incisions. We sought to determine whether carpal tunnel release using a single incision during basal joint arthroplasty is as effective as a two-incision approach in patients with concomitant carpal tunnel syndrome and basal thumb joint osteoarthritis. For this purpose, 40 patients were randomly allocated to either a single-incision or double-incision approach, all of whom completed the full follow-up period. The Boston Carpal Tunnel Questionnaire, QuickDASH, and a 10-point visual analog scale pain-severity rating were obtained from patients 3, 6 and 12months post-operatively. The two treatment groups experienced comparable, progressive improvement in all symptom-, function-, and pain-related outcomes, with mean surgery time significantly shorter with the single-incision approach, and four versus zero patients in the double-incision group developing pillar pain (p = 0.035). Concomitant basal thumb joint osteoarthritis and carpal tunnel syndrome might be effectively performed through a single-incision approach, potentially avoiding any morbidity classically associated with a second incision. Level II/Therapeutic Study. ClinicalTrials.gov: NCT04391751, 04/29/2020, retrospectively registered.

Double-Incision approach with suspension of the orbicularis oculi muscle and relieving of tension for upper eyelid rejuvenation in Asian women

In Asian women, upper eyelid skin laxity, lateral hooding, and upper eyelid and brow asymmetry in the aging upper eyelid are prominently and frequently seen. It is difficult to completely resolve these problems with the classical single-incision method. In this study, we investigate the utility of a double-incision approach to address aging-related changes of the upper eyelid. From September 2017 to March 2019, 51 patients underwent this procedure. Through a sub-brow incision, the skin and subcutaneous tissue were excised and the orbicularis oculi muscle (OOM) flap and muscular-cutaneous flap were separated. The OOM flap was lifted and fixed to the periosteum through the sub-brow fat pad and covered by the upper muscular-cutaneous flap. Through an eyelid crease incision, the supratarsal upper eyelid skin, muscle, and orbital fat were excised, excessive tension was alleviated, and double-fold eyelids were adjusted and reshaped if needed. The results were evaluated by asking the surgeon and patient involved to allocate a categorical (poor, fair, good, very good, excellent) scores and comparisons between pre- and postoperative brow position. The average follow-up period was 12 months. Most patients were satisfied with the results, barring two cases each of vomiting and transient numbness over the forehead region and three revisions. The mean surgeon and patient categorical scores associated with satisfaction with the overall outcome at 6 months were 4.2 ± 0.6 (range 3.0-5.0) and 4.0 ± 0.7 (range 2.0-5.0), respectively. The brow position was stable during follow-up period. A double-incision approach is a safe, effective, durable, and esthetic way for treating patients presenting with upper eyelid aging.

Distal Biceps Tendon Repair Using a Modified Double-Incision Technique: Patient-Reported Outcomes With 10-Year Follow-up.

Background:In the setting of complete distal biceps tendon rupture, surgical repair has become the standard of care to restore optimal elbow function, but the optimal approach and method of tendon fixation are still subjects of debate and have remained controversial for more than half a century.Purpose:To evaluate patient-reported long-term outcomes after distal biceps tendon repair using a modified double-incision technique.Study Design:Case series; Level of evidence, 4.Methods:We reviewed primary distal biceps tendon repairs after isolated tendon rupture using the modified muscle-splitting double-incision approach and transosseous suture fixation technique described by Morrey et al (1985), which had been performed at our level 1 trauma center between January 2000 and December 2013. Outcome measures included the subjective elbow value (SEV), the Oxford Elbow Score (OES) with its 3 domains (function, pain, and social-psychological), a self-performed hook test, and the 3-level version of the EuroQoL 5-dimensional instrument (EQ-5D-3L) as a measure of health status. Levels of overall satisfaction were determined by asking whether the patient would consent to the operation again. In addition, patients were asked to report any complications.Results:A total of 30 patients met the inclusion criteria, and 25 patients were available for the survey. Mean age at the time of rupture was 47 years. All patients were male. Mean follow-up was 120 months (range, 57-207 months). The follow-up rate was 83.34%. The following outcome results were obtained: SEV, 88.16% ± 25.18%; OES, 43.80 ± 10.56 out of 48 points; OES Pain, 92.50% ± 23.03%; OES Function, 92.25% ± 22.19%; OES Social-Psychological, 89% ± 23.68%; EQ-5D-3L, 0.93 ± 0.21. All patients described a negative hook test. Patient-reported complications included painless limitation in forearm rotation in 8% of patients (n = 2); reduced flexion and forearm rotation strength with and without pain in 8% (n = 2) and 4% (n = 1), respectively; synostosis after 1 year requiring revision surgery in 4% (n = 1); and transient wrist drop in 4% (n = 1). The overall complication rate was 28% (7/25), and 96% (n = 24) would consent to the operation again.Conclusion:Despite the cited approach-related morbidity, we report an excellent patient-reported long-term outcome for the double-incision distal biceps repair technique.

Distal biceps tendon rupture: advantages and drawbacks of the anatomical reinsertion with a modified double incision approach

BackgroundDistal biceps tendon rupture occurs more often in middle-aged male population, involving the dominant arm. In this retrospective study, it’s been described the occurrence of the most frequent adverse events and the clinical outcomes of patients undergoing surgical repair of distal biceps tendon rupture with the modified Morrey’s double-incision approach, to determine better indications for patients with acute tendon injury.MethodsSixty-three patients with acute distal biceps tendon rupture treated with a modified double-incision technique between 2003 and 2015 were retrospectively evaluated at a mean 24 months of follow-up. Clinical evaluation including range of motion (ROM) and isometric strength recovery compared to the healthy contralateral side assessment, together with documentation of nerve injury, was performed. Patients were asked to answer DASH, OES and MEPS scores.ResultsThe ROM recovery showed excellent results compared to the healthy contralateral side.The reported major complications included: one case of proximal radio-ulnar synostosis, 3 cases of posterior interosseous nerve (PIN) palsy and one case of a-traumatic tendon re-rupture. Concerning minor complications, intermittent pain, ROM deficiency < 30° in flexion/extension and pronation/supination, isometric flexion strength deficiency < 30% and isometric supination strength deficiency < 60%, lateral antebrachial cutaneous nerve (LACBN) injury, were observed. The average DASH score was 8.5; the average OES was 41.5 and the MEPS was 96.3.ConclusionThe Morrey modified double-incision technique finds its indication in young and active patients if performed within 2 weeks from injury. If performed by experienced surgeons, the advantages can exceed the drawbacks of possible complications.

Rupture aiguë et totale du biceps distal : fixation transosseuse par bouton cortical et ancre. Une expérience monocentrique

IntroductionThere remains as of yet no consensus on the optimal treatment for total or partial distal biceps tendon repairs. As such, the purpose of this study was to assess functional outcome, the impact of complications and cost effectiveness, in patients undergoing primary distal biceps tendon repair by either cortical button (CB), transosseous suture (TO) or suture anchor (SA). HypothesisThere is no difference in functional outcome and cost effectiveness, in patients undergoing distal biceps tendon repair. Material & methodsA retrospective analysis was performed on prospectively collected data from 47 consecutive patients treated for total or partial distal biceps tendon rupture. Functional outcome was assessed by the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. Strength measurements (e.g., flexion, supination and pronation) in the operated and non-operated extremities were recorded with the use of a dynamometer. Furthermore, all complications, as well as their impact on functional outcome, and costs for surgical intervention were evaluated. ResultsMinimum follow-up time was 35 weeks, average 46.3±13.8 weeks. The overall DASH score was 7.9±4.7. There were no differences in functional outcome (e.g., DASH score) between CB, TO, SA (p=0.32), nor were there differences in regards to strength (supination, flexion and pronation) (p=0.60) and ability to return to work and sports activity. The total complication rate was 21.6%. Complications had a significant impact on functional outcome (p=0.003). Re-rupture occurred 2 times in the SA group. In 5 patients, revisional surgery had to be performed. The shortest operation times and the lowest material costs were observed in the TO group. (p=0.004). DiscussionAll reported fixation methods for total or partial distal biceps tendon rupture yielded good functional results. However, transosseous suture fixation for total distal biceps tendon rupture, performed through a double incision approach by an experienced surgeon, seems to be a simple, inexpensive and successful method, offering satisfying clinical results. Level of evidenceIV, a retrospective, comparative study.

Use of cortical buttons for the fixation of the distal biceps tendon in combination with the double-incision technique—the relationship between the drill trajectory and the proximity to the posterior interosseous nerve: a cadaveric study

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. 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. 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. Because of the potential risk of PIN injuries, the use of cortical button fixation in combination with the double-incision approach cannot be recommended.

Surgical Treatment of Distal Biceps Tendon Ruptures: An Analysis of Complications in 784 Surgical Repairs

Background: Distal biceps brachii tendon ruptures lead to substantial deficits in elbow flexion and supination; surgical repair restores muscle strength and endurance. Purpose: To examine clinical and surgical outcomes for distal biceps tendon repairs in a large, multispecialty, integrated health care system. Study Design: Cohort study; Level of evidence, 3. Methods: Retrospective cohort study of distal biceps tendon repairs performed between January 1, 2008, and December 31, 2015. The repair methods were classified as double-incision approach using bone tunnel–suture fixation or anterior single-incision approach. Anterior single incisions were further classified according to the fixation method: cortical button alone, cortical button and interference screw, or suture anchors alone. Patient demographics, surgeon characteristics, range of motion, and complications were analyzed for all repair types. Results: Of the 784 repairs that met the inclusion criteria, 639 (81.5%) were single-incision approaches. When comparing double-incision and single-incision repairs, there was a significantly higher rate of posterior interosseous nerve palsy (3.4% vs 0.8%, P = .010), heterotopic bone formation (7.6% vs 2.7%, P = .004), and reoperation (8.3% vs 2.3%, P < .001). The most common nerve complication encountered was a lateral antebrachial cutaneous nerve palsy (n = 162), which was significantly more common in the single-incision repairs than in the double-incision repairs (24.4% vs 4.1%, P < .001). When excluding lateral antebrachial cutaneous nerve palsies, there was no significant difference in the overall nerve palsies between single-incision and double-incision (5.8% vs 6.9%, P = .612). The overall rate of tendon rerupture was 1.9% (single incision, 1.6%; double incision, 2.8%; P = .327). The overall rate of postoperative wound infection was 1.5% (single incision, 1.3%; double incision, 2.8%; P = .182). The average time from surgery to release from medical care was 14.4 weeks (single incision, 14 weeks; double incision, 16 weeks; P = .286). Patients treated with cortical button plus interference screw were released significantly sooner than were patients with other single-incision repair types (13.1 ± 8.01 weeks, P = .011). There were no significant differences in rates of motor neurapraxia, infection, rerupture, and reoperation with regard to surgeon’s years of practice, fellowship training, or case volume. Conclusion: The surgical repair of distal biceps tendon ruptures has an overall low rate of serious complications, regardless of approach or technique. However, the double-incision technique has a higher rate of posterior interosseous nerve palsy, heterotopic bone formation, and reoperation rate. Surgeon’s years of practice, fellowship training, and case volume do not affect the rate of major complications.

Mini-invasive technique for bone patellar tendon bone harvesting: its superiority in reducing anterior knee pain following ACL reconstruction

Arthroscopically-assisted ACL-reconstructions are currently reliable, reproducible. Residual anterior knee symptoms however, especially after patellar-BTB graft use, are not uncommon occurrences. Contributing factors are numerous and include injury to the saphenous nerve infrapatellar branches and/or histologic changes at the harvest site. The use of mini invasive harvesting technique decreases the risk of injury to the saphenous nerve infrapatellar branches while preserving the peritenon. The double-incision approach significantly reduces the mid-term incidence of anterior knee pain after ACL-reconstruction. Additionally, this technique markedly decreases the occurrence of sensory disorders and the extent of hypoesthesia. We thus advocate the use of a double-incision graft harvesting technique in ACL-reconstruction using a patellar-bone-tendon-bone transplant.

Controversies in the surgical treatment of distal biceps tendon ruptures: single versus double-incision repairs

Distal biceps tendon ruptures are most often seen in middle-aged males engaged in heavy lifting activities. Little controversy exists regarding the optimal treatment of these injuries. Restoration of full function requires operative repair and is indicated in most injuries. Distal biceps tendon repair surgery can be safely and successfully executed with either a single- or double-incision approach. The biomechanical evidence has shown that newer fixation options, including suture anchors, a tenodesis screw, and a cortical button, provide comparable, and in some instances greater, fixation strength than transosseous tunnels. Most methods of fixation provide adequate strength to allow early active range of motion (AROM) of the elbow, which has been a recent trend in rehabilitation following surgery. The advantages of single and double-incision repairs, in terms of preventing postoperative complications, have largely disappeared, as complications have decreased compared to older fixation techniques, and are similar between groups using modern surgical techniques. However, complications persist, despite advances in surgical techniques that are usually either transient or have little effect on function. Typically, full or near full return of function can be expected following distal biceps tendon repair using modern surgical approaches with a variety of fixation options.

Complex fractures of tiblal plateau treated by modified double-incision approach and double plating

复杂胫骨平台骨折的治疗一直是创伤骨科的难题,治疗不当会严重影响膝关节功能.我院自2002年3月至2007年10月,选择Schatzker Ⅴ、Ⅵ型胫骨平台骨折中一侧损伤较轻而另一侧损伤较重的21例患者.采用改良双切口入路结合双钢板治疗,取得良好效果,现报告如下。

Double-incision mini-invasive technique for BTB Harvesting: Its superiority in reducing anterior knee pain following ACL reconstruction

Arthroscopically-assisted ACL-reconstructions are currently reliable, reproducible and thoroughly used methods. Residual anterior knee symptoms however, especially after patellar-BTB graft use, are not uncommon occurrences following ACL-reconstructions, and can downgrade patient's satisfaction. Anterior knee pain contributing factors are numerous and include injury to the saphenous nerve infrapatellar branches (SNIB) and/or histologic changes at the harvest site. We thus preferably suggest a double-incision minimal approach for the patellar transplant harvesting stage in order to prevent injury to the SNIB. This technical variation decreases the risk of injury to the saphenous nerve infrapatellar branches while preserving the peritenon. Prospective controlled trial. Two groups were alternatively constituted in 2004: ligament reconstructions were either performed via a two-incisions approach during the first 2004 semester or via a single-incision approach during the second 2004 semester. Pain, even at a mild level, was evaluated. Patients were assessed using objective pain provocative tests and sensory assessment, a Lille University femoropattelar score, the IKDC Knee evaluation, the SF36 quality of life score in combination with radiographic and ultrasonographic investigations. Forty patients were reviewed at a mean 33 months follow-up delay: 21 of these had a double-incision approach and 19 had a single-incision approach. Four patients from the double-incision sub-group and 11 from the single-incision sub-group reported anterior knee pain (p<0.01). The knee-walking test came out normal in 11 patients from the double-incision sub-group and in three from the single-incision sub-group (p<0.02). The Lille University patello-femoral score was 91/100, demonstrating no significant difference. At follow-up, sensory disorders were observed in 17 patients from the single-incision sub-group and in nine from the double-incision sub-group (p<0.002). However, no statistical correlation could be established between anterior knee pains and sensorial disturbances. SF36 and IKDC objective and subjective scores were similar in both groups. Ultrasonographic findings revealed a lesser degree of patellar tendon thickening in the double-incision sub-group. However, no statistically significant differences definitely emerged between the two groups (p=0.50). The results of this study strongly support our main hypothesis: The double-incision approach significantly reduces the mid-term incidence of anterior knee pains after ACL-reconstructions. Additionally, this technical variation markedly decreased the occurrence of sensory disorders and the extent of hypoesthesia. We thus advocate the use of a double-incision graft harvesting technique in ACL-reconstructions using a patellar-bone-tendon-bone transplant.