J Shoulder Elbow Surg (2016) 25, 349354

www.elsevier.com/locate/ymse

Distal biceps tendon repair: comparison of clinical

and radiological outcome between bioabsorbable
and nonabsorbable screws
Pieter Caekebeke, MD*, Kristoff Corten, MD, PhD, Joris Duerinckx, MD
Orthopaedic Department, Ziekenhuis Oost-Limburg, Genk, Belgium
Background: Distal biceps tendon repair to the radial tuberosity can be conducted by means of an interference screw in combination with a transosseous button. Bioabsorbable interference screws have been
associated with complications such as severe osteolytic reactions. We questioned whether patients with a
distal biceps tendon repair with bioabsorbable poly-L-lactide (PLLA) screws had different functional, clinical, and radiologic outcome than patients with nonabsorbable poly-ether ether ketone (PEEK) screws.
Methods: Between 2010 and 2014, 23 patients with an acute distal biceps tendon rupture were treated
with reinsertion of the distal biceps tendon in a bone tunnel at the radial tuberosity through a single anterior incision using a transosseous button combined with an interference screw. A PLLA screw was used
in 12 patients and a PEEK screw in 11 patients. All patients were retrospectively evaluated with a minimal
follow-up of 1 year clinically and by means of the visual analog scale for pain, Mayo Elbow Performance Score, and Disabilities of Arm, Shoulder and Hand Outcome Measure score. Bone tunnel volume
was measured with computed tomography segmentation.
Results: Elbow mobility and arm and forearm circumference were symmetric for all patients. The visual
analog scale for pain was 0.2 in the PLLA group and 0.7 in the PEEK group. The Disabilities of Arm,
Shoulder and Hand score and Mayo Elbow Performance Score were 5.4 and 98.7 in the PLLA group vs.
3.1 and 95.9 in the PEEK group. Bone tunnel enlargement of 43% in the PLLA and 38% in the PEEK
group was noted.
Conclusions: Clinical and functional outcome at more than 1 year after distal biceps tendon repair was
excellent in both groups. Bone tunnel widening occurred in all patients.
Level of evidence: Level III; Retrospective Cohort Design; Treatment Study
2016 Journal of Shoulder and Elbow Surgery Board of Trustees
Keywords: Biceps tendon; osteolysis; PLLA; PEEK; interference; repair

Distal biceps tendon ruptures are relatively uncommon. Approximately 3% of all biceps tendon ruptures are at the distal
Ethical approval from the Institutional Ethics Committee (B371201422732)
was issued on June 1, 2014.
*Reprint requests: Pieter Caekebeke, MD, Domentveldstraat 42, B-1790
Affligem, Belgium.
E-mail address: caekebeke.pieter@hotmail.com (P. Caekebeke).

insertion.43 The most commonly described mechanism is an

excessive eccentric contraction of the biceps brachii with the
elbow held in a flexed and supinated position.44
Operative treatment improves flexion and supination
strength and endurance compared with conservative
treatment.3,10 Surgery can be associated with complications
such as nerve injuries, heterotopic ossification, and traumatic reruptures.25,30,43 Anatomic repair of the distal biceps tendon

1058-2746/$ - see front matter 2016 Journal of Shoulder and Elbow Surgery Board of Trustees
http://dx.doi.org/10.1016/j.jse.2015.12.007

350
can be performed using a 1- or 2-incision technique.14,18 To
date, no consensus has been reached regarding the preferred approach.
Multiple fixation methods have been proposed since the
transosseous suture technique described by Morrey et al.31,35,38,48
Biomechanical studies comparing the load to failure of suture
anchors, button fixation, and interference screws show variable results.2,12,23,33,41,45 An interference screw combined with
a transosseous button can increase the fixation strength.14,15,28,47
Initially, biodegradable poly-L-lactide (PLLA) screws were
proposed because of the theoretic advantages such as biocompatibility, gradual degradation, and replacement by bone.1,7
However, specific complications such as (severe) osteolysis, foreign body reactions, cyst formation, and screw breakage
were reported.5,8,29,49,52 Although no adverse correlation was
found between radiologic osteolysis and functional outcome,
concern has grown following reported fractures of the femoral
and tibial tunnels.15,29,40,47,49 Owing to the smaller size of the
proximal radius, the risk of fracture through the surgically
created bone tunnel for distal biceps tendon repair could be
a potential problem.
The risk of osteolysis might be lower when a nonabsorbable poly-ether ether ketone (PEEK) screw is used. Good
clinical results with these screws have been reported, but osteolysis has also been described.22,50 To our knowledge, no
data on the use of PEEK screws in distal biceps tendon repair
have been presented yet.
The first goal of our study was to compare the clinical and
functional results of bioabsorbable and nonabsorbable screws
in distal biceps tendon repair. The second goal was to evaluate and compare tunnel widening and osteolytic reactions
between both groups.

Materials and methods

This is a retrospective case-control study in which the first
author (P.C.) evaluated all consecutive patients treated for acute
distal biceps tendon rupture at our institution between October
2010 and May 2014.
The senior author (J.D.) performed all surgeries through
a single anterior incision technique, as described previously.12,23
Surgical exploration was performed through a 4-cm longitudinal incision starting centrally at the elbow crease and
extending distally. In case of marked proximal retraction or
adherence of the distal biceps tendon stump, the incision was
extended proximally over the elbow crease in a lazy-S shape.
After dbridement of the biceps tendon to healthy tissue, a
partially absorbable suture (FiberLoop 2; Arthrex, Naples, FL,
USA) was passed in a whipstitch fashion in the distal 20 mm
of the tendon so that its ends emerged at the distal tendon
end.
With the forearm held in hypersupination, a guide pin
(3.2 mm) was drilled through the radial tuberosity until it
passed through the opposite cortex. Care was taken with the
pin position to not damage the posterior interosseus nerve.

P. Caekebeke et al.
The guidewire was then over reamed through 1 cortex with
a 7-, 7.5-, 8-, or 8.5-mm cannulated drill bit. The depth of
this bone tunnel was similar to the length of the interference screw (ie, 10 or 12 mm). An interference screw of
7 10 mm was chosen for drill holes of 7 or 7.5 mm, and
an interference screw of 8 12 mm was used for drill holes
of 8 or 8.5 mm.
Next, the tendon was inserted into the bone tunnel using
a transosseous titanium Biceps Button (Arthrex) and the
tension-slide technique.46 Finally, the appropriate interference screw was placed over 1 end of the suture wire into the
drill hole until flush with the cortex, and the wire was sutured
over the screw for a strong fixation.
From October 2010 to October 2012, the PLLA
bioabsorbable interference screw (Arthrex) was used in 12
patients. From October 2012 to May 2014, 11 patients were
treated with a nonabsorbable screw made of PEEK (OPTIMA
from Invibio, Arthrex).
The elbow was immobilized in 90 of flexion and neutral
rotation for 10 days, after which active and passive range of
motion exercises were started. Muscle strengthening commenced at 2 months postoperatively. Controlled, unlimited
lifting was allowed at 3 months. Sport activities were allowed
at 5 months.
Patients were invited for clinical, functional, and conebeam computed tomography (CT) scan evaluation. Passive
and active range of motion of the elbow and forearm were
measured using a goniometer. Arm and forearm circumference was measured at the highest point of the biceps and 4 cm
distal to the elbow crease, respectively.
Functional evaluation included the Mayo Elbow Performance Score (MEPS), the Dutch version of the Disabilities
of the Arm, Shoulder and Hand (DASH) questionnaire, and
the visual analog scale for pain. The MEPS is a widely applied
measure of function of the elbow. It is a clinician-completed
score that includes 4 categories: pain, motion, stability, and
the ability to perform 5 functional tasks. The DASH score
is a validated patient-oriented rating scale that analyzes factors
involved in activities of daily living, followed by optional questions. Complications were recorded. Patients with other
ipsilateral upper limb disease were excluded.
Cone-beam CT images of the proximal radius (Fig. 1) were
used to calculate tunnel volumes as described and validated
by Robbrecht et al.42 This technique uses MIMICS 14 image
processing software (Materialise, Leuven, Belgium) to calculate tunnel diameters and volume by semiautomated
segmentation. This measurement was performed independently by 2 observers (P.C. and J.D.) and was repeated
with an interval of 2 weeks. The surgically created tunnel
volume was calculated as the volume of a cylinder
( radius2 height), based on the diameter of the cannulated drill, as mentioned in the operative notes, and the length
of the screw that was used. Tunnel widening was calculated
by measuring the proportional increase in tunnel volume
between the initial volume and the volume measured with the
cone-beam CT scan.

Distal biceps interference screw comparison

(a)

Figure 1

351

(b)

Cone-beam computed tomography images of a distal biceps tendon repair using a PLLA screw (a) and a PEEK screw (b).

Distribution of variables is given as mean, standard deviation, and range. Comparison between the 2 groups was
performed using the Student t test. Intraobserver and
interobserver reliability was assessed using a 2-way mixed,
consistency, average-measures interclass correlation (ICC).34
SPSS 23 software (IBM Corp, Armonk, NY, USA) was used.

Results
All patients had a trauma mechanism suggestive of excessive eccentric loading of a flexed and supinated arm. Patient
demographics are listed in Table I. The tendon repair in 1
patient was with a PLLA screw on the left side and a PEEK
screw on the right side. The mean time to surgery was 8 days
in both groups (range, 2-14 days for PLLA; range 0-24 days
for PEEK).
One patient in the PEEK group had marked retraction of
the distal biceps tendon with an extension deficit of 80 after
reinsertion. In this patient, the postoperative rehabilitation was
protected by a hinged elbow brace with an extension block
that was progressively weaned to full extension by 6 weeks.
A 7- 10-mm screw was used in most patients. An 8- 12mm screw was used in 2 patients in the PLLA group and in
1 patient in the PEEK group.
Five patients experienced postoperative hypoesthesia in the
innervation area of the lateral antebrachial cutaneous nerve.
This resolved in all cases. A rerupture that required revision
surgery occurred in 1 patient in the PEEK group due to a
sudden forceful eccentric load. This patient was excluded from
the current study.
Mean follow-up was 35 months (range, 24-48 months) for
the PLLA group and 16 months (range, 12-24 months) for
the PEEK group. Arm and forearm circumference were symmetric for all patients. VAS for pain was 0.2 in the PLLA
and 0.7 (P = .21) in the PEEK group. DASH scores and MEPS

were 5.4 and 98.7 in the PLLA group (P = .29) vs. 3.1 and
95.9 in the PEEK group (P = .34; Table I).
We calculated an initial bone tunnel volume of 460 mm3
in the PLLA group and 440 mm3 in the PEEK group (P = .54).
With cone-beam CT segmentation, a bone tunnel volume of
665 mm3 in the PLLA and 610 mm3 in the PEEK group
(P = .33) was measured at more than 1 year after surgery. This
implicates that postoperative tunnel widening is present in
both groups (44% in PLLA vs. 38% in PEEK, P = .4). The
intraobserver and interobserver reliability of our CT measurements was excellent (ICC = 0.943 and ICC = 0.9213,
respectively).11 None of the PLLA screws were replaced by
bone. Closure of the cortical bone over the bone tunnel at the
radial tuberosity occurred in 2 PLLA patients and in 3 PEEK
patients (Fig. 2). CT scans demonstrated minor heterotopic
ossifications in 1 patient with a PLLA screw and in 2 patients with a PEEK screw.

Discussion
This is the first study that compares the clinical, functional,
and radiologic outcome of distal biceps tendon repair using
a PLLA or PEEK interference screw combined with a
transosseous button. The clinical and functional results were
excellent for both groups and comparable with those of previous studies using different tendon-fixation techniques.
Popatov et al40 reported an average MEPS of 91.4 and DASH
(11-item version) score of 15.9 with the solitary use of a
bioabsorbable tenodesis screw. Other reports on the Endobutton
technique describe MEPS averaging 97 and 96 and a DASH
(11-item version) score of 7 and 5.38,41 Another study of
Endobutton fixation reported a MEPS of 94.2
We noted only minor complications with the single anterior incision. Temporary sensory loss in the distribution area
of the lateral antebrachial cutaneous nerve was the most

352

P. Caekebeke et al.

Table I
Variable

Demographics and functional and clinical outcome

*

PLLA
group

(n = 12)
Age, y
Male sex
Side
Dominant
Nondominant
Time to
operation, d
Extension,
Injured
Normal
Flexion,
Injured
Normal
Pronation,
Injured
Normal
Supination,
Injured
Normal
Arm diameter, cm
Injured
Normal
Forearm
diameter, cm
Injured
Normal
Distance
bicepselbow
crease, cm
Injured
Normal
VAS
DASH
MEPS
Tunnel widening, %

PEEK
group

Overall
P

(n = 11)

45 7
12

45 10
11

5
7
88

9
2
8 10
1

.54

.98
1

01
01
.82
135 4
134 4

1
132 6
132 7

.34
74 10
77 6

.17
73 7
77 6

.7
83 10
85 7

.13
77 10
84 8

.8
36 2
36 2

.93
34 2
34 2

.21
31 1
30 0.8

.55
29 1
29 1

.48

4 0.7
4 0.7
0.2 0.6
5.4 5.9
98.7 4.3
44 13

Figure 2 Closure of the cortical bone over the bone tunnel is seen
at the radial tuberosity.
.56

3 0.4
4 0.3
0.7 1
3.1 3.9
95.9 7.2
38 12

.21
.29
.34
.4

DASH, Disabilities of Arm, Shoulder, and Hand; MEPS, Mayo Elbow Performance Score; PEEK, poly-ether ether ketone; PLLA, poly-L-Lactide; VAS,
visual analog scale.
* Continuous data are shown as the mean standard deviation and
categoric data as number.

common complication and was present in 22% of patients.

Other series reported this complication in 7% to 57% of
patients.14,27 Heterotopic ossification was present in 8% of patients where a PLLA screw was used and in 18% of our PEEK
patients. In other series using bioabsorbable screws severe
complications, such as foreign body reactions with aseptic
swelling, sinus formation,40 and screw breakage,20,40 were encountered. None of these complications occurred in our
patients.
We measured 44% tunnel widening in our PLLA group.
Average tunnel widening after bioabsorbable screw fixation
has been estimated between 12% and 77%.9,13,32,40 Foreign body

immune response,17 bone necrosis secondary to drilling, and

tendon-tunnel motion (windshield wipering) have been suggested as possible causes.17,24,39 The use of PEEK screws in
our series was associated with 38% tunnel widening, exceeding the 24% that has been described in reconstructive knee
ligament procedures.50 Preliminary research suggests only
minimal immune response to PEEK material.21 A possible explanation for tunnel widening could be tendon-tunnel motion,
but interference screw fixation is associated with the least
amount of micromotion compared with other techniques.33
Further research and comparison with other fixation techniques is mandatory to clarify the etiology of this phenomenon.
None of the PLLA screws in our series had any bony replacement 2 to 4 years after surgery. PLLA biodegradation
starts 3 years postoperatively,26,37,40 and remnants of PLLA
screws have been found to persist as long as 7 years.4,6 The
theoretical advantage of bioabsorbable screws is that they are
eventually replaced by bone. PEEK screws do not resorb and
do not carry the risk of excessive osteolytic reaction as do
bioabsorbable screws. Studies regarding anterior cruciate ligament reconstruction show that bone tunnel healing may take
6 to 12 months.16,19,36,51 Because the patients in our PEEK group
were reviewed between 1 and 2 years postoperatively, we do
not expect that the osteolysis around a PEEK screw will evolve
further because the tendon has become reattached. For this
reason, we currently prefer transosseous button fixation in combination with nonabsorbable PEEK screws.

Distal biceps interference screw comparison

Our study has several limitations. First, the number of patients studied is small.
Second, the initial bone tunnel volume was calculated and
not measured directly. No CT images were made immediately after surgery to define the initial bone tunnel volume.
This should not be a concern, because Popatov et al40 reported no difference between the calculated initial volume
of the drill hole and the radiographically determined tunnel
volume.
Third, follow-up time for the PLLA and PEEK groups was
not equal. Biodegradation of the PLLA screws commences
from 3 years onwards. Further follow-up of the PLLA group
is warranted. A follow-up assessment of our patients at minimally 7 years after surgery is recommended.

Conclusion
Similar widening of the bone tunnel occurs with the use
of bioabsorbable PLLA and nonabsorbable PEEK screws
at short-term follow-up after distal biceps tendon repair
where an interference screw is combined with a
transosseous button. Although the functional results in our
series were excellent and complications minor, the rare but
severe osteolytic reactions that have been described in other
studies with the use of PLLA screws remain a potential
concern. We therefore currently use PEEK screws in cases
where an interference screw is preferred for tendon fixation.

Disclaimer
The authors, their immediate families, and any research
foundations with which they are affiliated have not received any financial payments or other benefits from any
commercial entity related to the subject of this article.

References
1. Ambrose CG, Clanton TO. Bioabsorbable implants: review of clinical
experience in orthopedic surgery. Ann Biomed Eng 2004;32:171-7.
2. Bain GI, Prem H, Heptinstall RJ, Verhellen R, Paix D. Repair of distal
biceps tendon rupture: a new technique using the Endobutton. J Shoulder
Elbow Surg 2000;9:120-6.
3. Baker BE, Bierwagen D. Rupture of the distal tendon of the biceps
brachii. Operative versus non-operative treatment. J Bone Joint Surg Am
1985;67:414-7.
4. Barber FA, Elrod BF, McGuire DA, Paulos LE. Bioscrew fixation of
patellar tendon autografts. Biomaterials 2000;21:2623-9.
5. Bergsma EJ, Rozema FR, Bos RR, de Bruijn WC. Foreign body reactions
to resorbable poly(L-lactide) bone plates and screws used for the fixation
of unstable zygomatic fractures. J Oral Maxillofac Surg 1993;51:666-70.
6. Blasier RD, Bucholz R, Cole W, Johnson LL, Makela EA. Bioresorbable
implants: applications in orthopaedic surgery. Instr Course Lect
1997;46:531-46.
7. Bostman O, Pihlajamaki H. Clinical biocompatibility of biodegradable
orthopaedic implants for internal fixation: a review. Biomaterials
2000;21:2615-21.

353
8. Bostman OM, Pihlajamaki HK. Adverse tissue reactions to bioabsorbable
fixation devices. Clin Orthop Relat Res 2000;371:216-27.
9. Buelow JU, Siebold R, Ellermann A. A prospective evaluation of tunnel
enlargement in anterior cruciate ligament reconstruction with hamstrings:
extracortical versus anatomical fixation. Knee Surg Sports Traumatol
Arthrosc 2002;10:80-5. http://dx.doi.org/10.1007/s00167-001-0267-6
10. Chillemi C, Marinelli M, De Cupis V. Rupture of the distal biceps brachii
tendon: conservative treatment versus anatomic reinsertionclinical and
radiological evaluation after 2 years. Arch Orthop Trauma Surg
2007;127:705-8. http://dx.doi.org/10.1007/s00402-007-0326-7
11. Cicchetti D. Guidelines, criteria, and rules of thumb for evaluating
normed and standardized assessment instruments in psychology. Psychol
Assess 1994;6:284-90.
12. Cusick MC, Cottrell BJ, Cain R, Mighell MA. Low incidence of
tendon rerupture after distal biceps repair by cortical button
and interference screw. J Shoulder Elbow Surg 2014;23:1532-6.
http://dx.doi.org/10.1016/j.jse.2014.04.013
13. Drogset JO, Grntvedt T, Myhr G. Magnetic resonance imaging
analysis of bioabsorbable interference screws used for fixation of
bone-patellar tendon-bone autografts in endoscopic reconstruction of
the anterior cruciate ligament. Am J Sports Med 2006;34:1164-9.
http://dx.doi.org/10.1177/0363546505285384
14. Eardley WG, Odak S, Adesina TS, Jeavons RP, McVie JL. Bioabsorbable
interference screw fixation of distal biceps ruptures through a
single anterior incision: a single-surgeon case series and review of
the literature. Arch Orthop Trauma Surg 2010;130:875-81.
http://dx.doi.org/10.1007/s00402-009-0974-x
15. Fenton P, Qureshi F, Ali A, Potter D. Distal biceps tendon rupture: a new
repair technique in 14 patients using the biotenodesis screw. Am J Sports
Med 2009;37:2009-15. http://dx.doi.org/10.1177/0363546509335465
16. Fu FH, Bennett CH, Lattermann C, Ma CB. Current trends in anterior
cruciate ligament reconstruction. Part 1: biology and biomechanics of
reconstruction. Am J Sports Med 1999;27:821-30.
17. Fules PJ, Madhav RT, Goddard RK, Newman-Sanders A, Mowbray MA.
Evaluation of tibial bone tunnel enlargement using MRI scan
cross-sectional area measurement after autologous hamstring tendon
ACL replacement. Knee 2003;10:87-91. http://dx.doi.org/10.1016/S0968
-0160(02)00086-8
18. Grewal R, Athwal GS, MacDermid JC, Faber KJ, Drosdowech DS,
El-Hawary R, et al. Single versus double-incision technique for the repair
of acute distal biceps tendon ruptures: a randomized clinical trial. J Bone
Joint Surg Am 2012;94:1166-74. http://dx.doi.org/10.2106/JBJS.K.00436
19. Gulotta LV, Rodeo SA. Biology of autograft and allograft healing in
anterior cruciate ligament reconstruction. Clin Sports Med 2007;26:50924. http://dx.doi.org/10.1016/j.csm.2007.06.007
20. Hall MP, Hergan DM, Sherman OH. Early fracture of a bioabsorbable
tibial interference screw after ACL reconstruction with subsequent
chondral injury. Orthopedics 2009;32:208. http://dx.doi.org/10
.3928/01477447-20090301-12
21. Hallab NJ, Bao QB, Brown T. Assessment of epidural versus intradiscal
biocompatibility of PEEK implant debris: an in vivo rabbit model.
Eur Spine J 2013;22:2740-51. http://dx.doi.org/10.1007/s00586-013
-2904-4
22. Haneveld H, Hug K, Diederichs G, Scheibel M, Gerhardt C. Arthroscopic
double-row repair of the rotator cuff: a comparison of bio-absorbable
and non-resorbable anchors regarding osseous reaction. Knee Surg
Sports Traumatol Arthrosc 2013;21:1647-54. http://dx.doi.org/10
.1007/s00167-013-2510-3
23. Heinzelmann AD, Savoie FH, Ramsey JR, Field LD, Mazzocca AD.
A combined technique for distal biceps repair using a soft tissue button
and biotenodesis interference screw. Am J Sports Med 2009;37:989-94.
http://dx.doi.org/10.1177/0363546508330130
24. Hoher J, Moller HD, Fu FH. Bone tunnel enlargement after anterior
cruciate ligament reconstruction: fact or fiction? Knee Surg Sports
Traumatol Arthrosc 1998;6:231-40.
25. Honma S, Tokiyoshi A, Kawai K, Koizumi M, Kodama K. Radial artery
running beneath the biceps tendon and its interrelation between the radial

354

26.

27.

28.

29.

30.

31.

32.

33.

34.
35.

36.

37.

38.

39.

recurrent arteries. Anat Sci Int 2008;83:232-8. http://dx.doi.org/10.1111/

j.1447-073X.2008.00231.x
Johnston M, Morse A, Arrington J, Pliner M, Gasser S. Resorption and
remodeling of hydroxyapatite-poly-L-lactic acid composite anterior
cruciate ligament interference screws. Arthroscopy 2011;27:1671-8.
http://dx.doi.org/10.1016/j.arthro.2011.06.036
Kelly EW, Morrey BF, ODriscoll SW. Complications of repair of the
distal biceps tendon with the modified two-incision technique. J Bone
Joint Surg Am 2000;82-A:1575-81.
Khan W, Agarwal M, Funk L. Repair of distal biceps tendon rupture
with the Biotenodesis screw. Arch Orthop Trauma Surg 2004;124:206-8.
http://dx.doi.org/10.1007/s00402-004-0639-8
Konan S, Haddad FS. Femoral fracture following knee ligament reconstruction surgery due to an unpredictable complication of bioabsorbable
screw fixation: a case report and review of literature. J Orthop Traumatol
2010;11:51-5. http://dx.doi.org/10.1007/s10195-009-0079-x
Lo EY, Li CS, Van den Bogaerde JM. The effect of drill trajectory on
proximity to the posterior interosseous nerve during cortical button distal
biceps repair. Arthroscopy 2011;27:1048-54. http://dx.doi.org/10
.1016/j.arthro.2011.03.084
Lynch SA, Beard DM, Renstrom PA. Repair of distal biceps tendon
rupture with suture anchors. Knee Surg Sports Traumatol Arthrosc
1999;7:125-31.
Ma CB, Francis K, Towers J, Irrgang J, Fu FH, Harner CH. Hamstring
anterior cruciate ligament reconstruction: a comparison of bioabsorbable
interference screw and endobutton-post fixation. Arthroscopy
2004;20:122-8. http://dx.doi.org/10.1016/j.arthro.2003.11.007
Mazzocca AD, Burton KJ, Romeo AA, Santangelo S, Adams DA,
Arciero RA. Biomechanical evaluation of 4 techniques of distal
biceps brachii tendon repair. Am J Sports Med 2007;35:252-8.
http://dx.doi.org/10.1177/0363546506294854
McGraw KO, Wong SP. Forming inferences about some intraclass
correlation coefficients. Psychol Methods 1996;1:30-46.
Morrey BF, Askew LJ, An KN, Dobyns JH. Rupture of the distal tendon
of the biceps brachii. A biomechanical study. J Bone Joint Surg Am
1985;67:418-21.
Nebelung W, Becker R, Urbach D, Ropke M, Roessner A. Histological
findings of tendon-bone healing following anterior cruciate ligament
reconstruction with hamstring grafts. Arch Orthop Trauma Surg
2003;123:158-63. http://dx.doi.org/10.1007/s00402-002-0463-y
Ntagiopoulos PG, Demey G, Tavernier T, Dejour D. Comparison of
resorption and remodeling of bioabsorbable interference screws in
anterior cruciate ligament reconstruction. Int Orthop 2015;39:697-706.
http://dx.doi.org/10.1007/s00264-014-2530-8
Peeters T, Ching-Soon NG, Jansen N, Sneyers C, Declercq G, Verstreken
F. Functional outcome after repair of distal biceps tendon ruptures using
the endobutton technique. J Shoulder Elbow Surg 2009;18:283-7.
http://dx.doi.org/10.1016/j.jse.2008.10.004
Peyrache MD, Djian P, Christel P, Witvoet J. Tibial tunnel enlargement
after anterior cruciate ligament reconstruction by autogenous
bone-patellar tendon-bone graft. Knee Surg Sports Traumatol Arthrosc
1996;4:2-8.

P. Caekebeke et al.
40. Potapov A, Laflamme YG, Gagnon S, Canet F, Rouleau DM. Progressive
osteolysis of the radius after distal biceps tendon repair with the
bioabsorbable screw. J Shoulder Elbow Surg 2011;20:819-26.
http://dx.doi.org/10.1016/j.jse.2011.02.021
41. Ranelle RG. Use of the Endobutton in repair of the distal biceps brachii
tendon. Proc (Bayl Univ Med Cent) 2007;20:235-6.
42. Robbrecht C, Claes S, Cromheecke M, Mahieu P, Kakavelakis K,
Victor J, et al. Reliability of a semi-automated 3D-CT measuring
method for tunnel diameters after anterior cruciate ligament
reconstruction: a comparison between soft-tissue single-bundle allograft
vs. autograft. Knee 2014;21:926-31. http://dx.doi.org/10.1016/j.knee
.2014.05.003
43. Sarda P, Qaddori A, Nauschutz F, Boulton L, Nanda R, Bayliss N. Distal
biceps tendon rupture: current concepts. Injury 2013;44:417-20.
http://dx.doi.org/10.1016/j.injury.2012.10.029
44. Schmidt CC, Jarrett CD, Brown BT. The distal biceps tendon. J Hand
Surg Am 2013;38:811-21, quiz 821. http://dx.doi.org/10.1016/j.jhsa
.2013.01.042
45. Sethi P, Obopilwe E, Rincon L, Miller S, Mazzocca A. Biomechanical
evaluation of distal biceps reconstruction with cortical button and
interference screw fixation. J Shoulder Elbow Surg 2010;19:53-7.
http://dx.doi.org/10.1016/j.jse.2009.05.007
46. Shields E, Olsen JR, Williams RB, Rouse L, Maloney M,
Voloshin I. Distal biceps brachii tendon repairs: a single-incision
technique using a cortical button with interference screw versus a
double-incision technique using suture fixation through bone tunnels.
Am J Sports Med 2015;43:1072-6. http://dx.doi.org/10.1177/
0363546515570465
47. Silva J, Eskander MS, Lareau C, DeAngelis NA. Treatment of distal
biceps tendon ruptures using a single-incision technique and a BioTenodesis screw. Orthopedics 2010;33:477. http://dx.doi.org/10
.3928/01477447-20100526-09
48. Strauch RJ, Michelson H, Rosenwasser MP. Repair of rupture of the
distal tendon of the biceps brachii. Review of the literature and report
of three cases treated with a single anterior incision and suture anchors.
Am J Orthop 1997;26:151-6.
49. Thietje R, Faschingbauer M, Nurnberg HJ. [Spontaneous fracture of the
tibia after replacement of the anterior cruciate ligament with absorbable
interference screws. A case report and review of the literature].
Unfallchirurg 2000;103:594-6.
50. Uzumcugil O, Yalcinkaya M, Ozturkmen Y, Dikmen G, Caniklioglu M.
Effect of PEEK polymer on tunnel widening after hamstring ACL
reconstruction. Orthopedics 2012;35:654-9. http://dx.doi.org/10.3928/
01477447-20120426-18
51. Weiler A, Hoffmann RF, Bail HJ, Rehm O, Sudkamp NP.
Tendon healing in a bone tunnel. Part II: histologic analysis
after biodegradable interference fit fixation in a model of anterior
cruciate ligament reconstruction in sheep. Arthroscopy 2002;18:
124-35.
52. Weiler A, Hoffmann RF, Stahelin AC, Helling HJ, Sudkamp NP.
Biodegradable implants in sports medicine: the biological base.
Arthroscopy 2000;16:305-21.