Reconstruction & Repair

Elbow reconstruction & repair: UCL/LUCL, tendon repair, paralytic elbow, and vascularized fibular transfer for massive bone loss.

Overview

Chronic tendon and ligament ruptures, such as those of the distal biceps or elbow medial ulnar collateral ligament (UCL), require careful selection between direct repair and reconstruction. Direct repair is preferred for chronic distal biceps tendon ruptures when possible [9]. When direct repair is not feasible, reconstruction with an autologous tendon graft results in predictably good outcomes [9]. Direct repair, autograft reconstruction, and allograft reconstruction are all viable treatment options for chronic distal biceps tendon ruptures with similar outcomes [1]. For chronic locked anterior shoulder dislocation where reduction is not possible, other surgical reconstruction should be considered [7]. In elbow UCL reconstruction, the modified docking procedure is a safe and predictable technique [59]. A good outcome in elbow medial UCL reconstruction depends on successful surgical reconstruction followed by a thorough rehabilitation program [8]. Revision reattachment of the distal biceps tendon results in acceptable functional outcomes [4].

Complex reconstructions involving bone or nerve deficits demand specialized expertise and timing. Complex procedures such as vascularized fibula autograft reconstruction should be performed by an experienced team [2]. Vascularized fibula autografts provide a long-term, durable outcome with excellent functional results after intercalary resection of the humerus for primary bone tumors, though complications may occur frequently in the first years [2]. Advances in preoperative evaluation and surgical reconstruction have improved functional outcomes in the management of humeral nonunion [3]. For pediatric populations, biologic reconstructions with viable bone autograft can provide more durable long-term reconstructions and growing reconstructions [20]. However, biologic reconstructions with viable bone autograft are associated with high short-term complication rates and donor-site morbidity [20]. Surgery for complex shoulder reconstruction in obstetric brachial plexus injury should be performed at 1 year old or younger to achieve the best results [12]. Neurotization to innervate the deltoid and biceps should be considered a viable adjunct treatment and part of a comprehensive reconstructive plan [18]. Regarding nerve grafting, the results of a series on C5 root grafting to the musculocutaneous nerve using pedicled, vascularized ulnar nerve grafts do not support strong recommendations to use vascularized nerve grafts in the reconstruction of large nerve defects [21].

Anatomy & Pathophysiology

Ligamentous & Soft Tissue Reconstruction

Reconstruction of chronically dislocated elbows, leveraging a thorough understanding of anatomy and biomechanics, can achieve functional and painless joints [36]. For ulnar collateral ligament (UCL) reconstruction, suspension button fixation reliably restores elbow kinematics to the intact state [44]. However, dynamic analyses using a 3-dimensional elbow model indicate that none of the configurations for double-strand lateral UCL reconstruction are isometric [39]. Current evidence regarding the optimal elbow flexion angle for graft fixation in UCL reconstruction possesses a high degree of fragility, requiring further studies with objective measurements [49]. Following UCL repairs and reconstructions, elbow range of motion is reliably preserved or improved with a predictable trajectory of rapid improvement within the first 2 to 4 months [58]. Reattachment of the flexor and extensor tendons at the epicondyle in elbow instability requires improved repair techniques for stabilizers of the elbow [68].

Kinematics & Biomechanics

Posterolateral rotatory instability (PLRI) of the elbow remains to be fully understood [64]. Tenotomy of the long head of the biceps tendon results in increased fatigue of the biceps and an improvement in isometric contraction in elbow flexion that does not reach the power of the contralateral healthy arm [48]. Both the Latarjet procedure with and without a coracoid bone block alter normal joint kinematics by shifting the humeral head apex posteriorly in external rotation [53]. Capsular repair in the modified Bristow procedure significantly alters normal glenohumeral kinematics [66].

Osseous Reconstruction & Arthroplasty

Endoprosthetic reconstruction of the proximal humerus provides a stable platform for elbow and hand function, but actual shoulder function is limited [40]. Hemiarthroplasty for distal humeral fractures maintains elbow range of motion and functional use compared with short-term studies [63]. Reconstruction after proximal ulnar resection using native bone provides good elbow function and is likely to provide long-term stability and durability [67].

Heterotopic Ossification & Contracture

Heterotopic ossification should be considered in patients with a mechanical block to function after elbow injury or surgery [51]. Surgical excision and perioperative prophylaxis using radiation therapy for heterotopic ossification of the elbow following burn injury results in significant gains in elbow motion and upper extremity function with few complications [55]. Operative treatment of elbow contracture in patients twenty-one years of age or younger can result in improved, but not normal, elbow motion in many but not all cases [60].

Surgical Approaches & Neuromuscular Management

The posterior (Boyd) approach to terrible triad injuries allows better visualization of the lateral structures for repair and confers excellent stability to the elbow joint [57]. Management of spastic elbow deformity in adult patients with upper motor neuron syndrome often combines several techniques in a single stage to provide an improved elbow position in patients with and without volitional control [65]. Lower trapezius muscle transfer for elbow extension in children with brachial plexus birth injury demonstrates significant improvements in elbow function and muscle strength without postoperative weakness in elbow flexion [61].

Classification

Contemporary Pectoralis Major Tear Classification: A system for pectoralis major tears incorporates injury timing, injury location, and standardized terminology addressing tear extent to reflect musculotendinous morphology [14].

Intraoperative Ulnar Nerve Instability Classification: A 4-category classification of intraoperative ulnar nerve instability is reproducible within and between reviewers [56].

Clinical Presentation

Chronic Distal Biceps Rupture: Direct repair, autograft reconstruction, or allograft reconstruction are all viable treatment options with similar outcomes [1]. When direct repair is not possible, reconstruction with an autologous tendon graft results in predictably good outcomes [9]. In delayed cases, a positive hook test may predict the need for graft reconstruction [25]. Revision reattachment of the distal biceps tendon results in acceptable functional outcomes [4]. Posterior interosseous nerve palsy after distal biceps repair typically resolves within 3 months, and at the latest, 5 months after surgery [29].

Distal Biceps Short Head Tears: These tears present acutely and have a poor natural history akin to complete tears [6]. Surgical repair of an isolated rupture of the separate insertion of the short head of biceps on the radial tuberosity can offer a good prognosis for functional recovery, including full strength and return to sporting activities [11]. Distal biceps short head tears have good outcomes with acute and delayed reconstruction [6].

Elbow Medial Ulnar Collateral Ligament (MUCL): A good outcome for elbow medial ulnar collateral ligament reconstruction depends on successful surgical reconstruction followed by a thorough rehabilitation program [8].

Cubital Tunnel Syndrome: Revision surgery for cubital tunnel syndrome can be offered in the setting of persistent or recurrent symptoms that are unexplained by an alternative diagnosis [15]. Patients undergoing revision surgery for cubital tunnel syndrome should be counseled that complete resolution of symptoms is unlikely [15].

Shoulder Reconstruction: Interposition graft repairs for irreparable rotator cuff tears have shown some promising 2-year outcomes in patient and physician-reported functional outcomes, regardless of graft type [30]. Surgery for complex shoulder reconstruction in obstetric brachial plexus injury should be performed at 1 year old or younger to achieve the best results [12].

Pectoralis Major Tears: A contemporary injury classification system for pectoralis major tears includes injury timing, injury location, and standardized terminology addressing tear extent to reflect musculotendinous morphology [14].

Quadriceps Tendon: Incomplete quadriceps tendon tears may be managed nonsurgically [13]. Complete quadriceps tendon ruptures are best treated with early surgical repair [13].

Distal Triceps Tendon: Primary repair of distal triceps tendon ruptures yields good, durable patient outcomes with minimal rerupture regardless of repair construct [17].

Achilles Tendon: Reconstructive options are detailed for chronic Achilles ruptures to serve as a framework for treating surgeons in these complex cases [16].

Tibialis Anterior Tendon: A two-stage silicone tube and interposition hamstring tendons graft protocol provides a very good functional outcome for traumatic tibialis anterior tendon rupture in young adults, even in delayed repairs complicated by infection [34].

Iliac Crest Graft Harvesting: If anatomical and technical considerations are respected, such as preserving the outer table and reconstructing the defect, patients can be spared iliac wing fracture following graft harvesting from the anterior iliac crest [35].

Vascularized Fibula Autograft: Vascularized fibula autografts provide a long-term, durable outcome with excellent functional results after intercalary resection of the humerus for primary bone tumors, though complications may occur frequently in the first years [2].

Humeral Nonunion: Advances in preoperative evaluation and surgical reconstruction have improved functional outcomes for humeral nonunion [3].

Investigations

MRI: MRI grading of UCL injuries can help predict return to play and the need for surgery [93].

Treatment

Distal Biceps and Triceps

Indications: Direct repair, autograft reconstruction, and allograft reconstruction are all viable treatment options for chronic distal biceps tendon ruptures with similar outcomes [1]. Distal biceps short head tears have a poor natural history akin to complete tears and have good outcomes with acute and delayed reconstruction [6]. Surgery remains an effective option for treatment failures of partial distal biceps tendon ruptures with no detrimental effects from prior conservative management [84]. Due to heterogeneity in rupture patterns, surgical procedures, and outcome measures, it is difficult to ascertain the superiority of one surgical technique over another for distal triceps tendon ruptures [31].

Surgical Approach / Technique: Anatomic direct repair of chronic distal biceps brachii tendon rupture without interposition graft optimizes the approach using the most secure fixation method and allows anatomic repair without loss of range of movement or function [24].

Pectoralis Major

Indications: Nonoperative management is feasible for elderly, low-demand patients with chronic pectoralis major tears, while repair should be reserved for younger, healthier patients with high functional demands [81].

Surgical Approach / Technique: Reconstruction using a human extracellular matrix scaffold (dermal allograft) for chronic pectoralis major tear can be expected to yield a strong repair and successful outcomes [5]. Transfer of the pectoralis major muscle for irreparable rupture of the subscapularis tendon produces high levels of subjective satisfaction with regard to pain relief, function, and stability [75]. Transfer of segmentally split pectoralis major for irreparable rupture of the subscapularis tendon requires further clinical research to determine whether it results in superior results for patient function or pain relief [90]. Treatment of long thoracic nerve palsy with pectoralis major transfer can significantly improve patient-oriented outcomes, but final clinical outcomes remain guarded and many patients have persistent pain regardless of the transfer technique selected [92].

Rotator Cuff and Subscapularis

Surgical Approach / Technique: Subscapularis transfer is a useful adjunct in the operative treatment of massive rotator cuff tears, facilitating closure of larger defects not amenable to simpler reconstructive techniques [33].

Elbow Ligaments and Instability

Surgical Approach / Technique: Treatment of ulnar collateral ligament (UCL) injuries depends on tear type, with nonoperative management for low-grade partial tears and UCL reconstruction as the gold standard for complete tears [10]. The docking technique for lateral ulnar collateral ligament (LUCL) reconstruction facilitates simple graft tensioning and excellent graft fixation [98].

Shoulder Instability and AC Joint

Indications: If reduction of chronic locked anterior shoulder dislocation is not possible, other surgical reconstruction should be considered [7]. Graft fixation techniques for coracoclavicular ligament reconstruction should be chosen with respect to the preoperative type of instability [100].

Surgical Approach / Technique: Suture button fixation in Latarjet has similar load to failure and clinical outcomes but lower bone resorption compared with screw fixation [85]. Clinically, suture button fixation demonstrated similar functional outcome and range of motion when compared with screw fixation, with the potential benefit of lower rates of graft resorption and hardware-related complications [85]. Non-rigid fixation of the glenoid bone block for recurrent anterior instability and major glenoid bone loss resulted in adequate bone graft healing and osseous incorporation [99]. Combined reconstruction with looped allograft and hardware C-C fixation carried the lowest failure rate for short-term failure rates after acromioclavicular joint reconstruction when controlling for multiple other factors [22]. Acromioclavicular joint reconstruction using peroneus brevis tendon allograft provides excellent initial fixation without metal fixators and enables aggressive therapeutic exercise and early return to sports [87]. Chronic acromioclavicular dislocations can be treated with multidirectional stabilization without grafting; the technique is simple, does not present major complications, and material extraction is unnecessary [28]. Conversion to anatomic coracoclavicular ligament reconstruction (ACCR) shows similar clinical outcomes compared to successful non-operative treatment in chronic primary type III to V acromioclavicular joint injuries at a minimum 5-year follow-up [96].

Humeral and Proximal Humerus Reconstruction

Surgical Approach / Technique: Vascularized fibula autografts are complex procedures that should be performed by an experienced team due to frequent complications in the first years, but successful reconstruction provides a long-term, durable outcome with excellent functional results [2]. Advances in preoperative evaluation and surgical reconstruction have improved functional outcomes for humeral nonunion [3]. Biologic reconstructions with viable bone autograft can provide more durable long-term reconstructions and growing reconstructions in the pediatric population at the expense of high short-term complication rates and donor-site morbidity [20]. Structural autografts used in shoulder joint reconstruction have varying outcomes, with some studies showing good stability and pain relief, while others note unpredictable results or donor site morbidity [79]. Reconstruction of the proximal humerus with allograft-prosthetic composite is associated with graft host nonunion as a common mode of failure [97]. Megaprosthetic replacement in complex distal humerus fractures in elderly patients is a salvage procedure that must be selected and narrowed down, as failure would cause even more complex situations [50]. Treatment of proximal humeral dysplasia epiphysealis hemimelica with custom hemiarthroplasty is a reasonable method to salvage the problem when nonsurgical management has failed [94].

Clavicle and Scapula

Surgical Approach / Technique: Surgical repair with plate fixation and bone grafting achieves high union rates with few complications for adolescent clavicle nonunions [104].

Nerve and Muscle Transfers

Surgical Approach / Technique: Neurotization to innervate the deltoid and biceps should be considered a viable adjunct treatment and part of a comprehensive reconstructive plan [18]. Lower trapezius transfer for brachial plexus injury requires additional studies to define and refine the surgical technique [32]. All reported surgical procedures for trapezius palsy demonstrate reduction in pain, with the best results from the Eden-Lange muscle transfer [77].

Soft Tissue and Flaps

Surgical Approach / Technique: With recent advancements in microsurgical techniques, harvesting flaps in a free-style manner has become a practical reality [26].

Elbow Stiffness and Arthroplasty

Indications: When prevention of elbow stiffness fails, nonoperative followed by operative treatment modalities can be pursued [52].

Surgical Approach / Technique: Treatment of elbow instability includes reconstruction of the soft-tissue envelope, revision of prosthetic components, and possibly the use of allografts [103].

Oncology and Limb Salvage

Other Considerations: The use of a reconstruction method appropriate for the needs of the patient and preoperative counseling regarding expected functional level and activity restrictions are critical for high postoperative satisfaction in limb salvage for neoplasms of the shoulder girdle [71].

Specific Patient Populations and Adjuncts

Other Considerations: Careful postoperative management can help achieve positive functional outcomes for rotator cuff tear reconstruction in wheelchair-bound paraplegic patients [83]. Selective ulnar nerve decompression, capsular branch denervation, and arthroscopic debridement should be considered for young patients with avascular necrosis of the distal humerus and radius due to improved pain relief and low morbidity [70]. Particular attention should be paid to prevention of complications, excellent perioperative pain control, and restoration of abduction during rehabilitation after reconstructive shoulder surgery to ensure patient satisfaction [95]. All-suture anchors offer benefits such as smaller size and bone preservation but require careful deployment to prevent gap formation and may be weakened by decortication [101].

Complications

Infection (PJI): Infection frequency after reconstructive shoulder surgery for proximal humerus tumors is similar to previously reported series, with no differences between reconstruction techniques [19]. Infection developed in 11.7% of patients with massive allografts, with no significant differences in age, graft type, or site between infected and non-infected groups [125]. Two-stage reimplantation for deep periprosthetic joint infection (PJI) following total elbow arthroplasty resulted in infection eradication in 69% of cases, with 31% considered treatment failures secondary to recurrent infection [117, 133]. One-stage revision arthroplasty with complete removal and reimplantation for periprosthetic shoulder infection results in lower reoperation rates for infection and similar clinical outcomes compared to one-stage component exchange and two-stage revision [138]. The brachioradialis muscle flap is a 1-stage procedure with no morbidity to the harvest site that provides stable and adequate coverage even in cases with postoperative infection [139].

Aseptic Loosening / Failure: Both acellular dermal allograft and tensor fascia lata autograft demonstrate high rates of complications and failures at a minimum 2-year follow-up [137]. The revision rate for UCLR with allograft appears greater compared to UCLR with autograft, although this may be secondary to limited allograft literature [135]. Limb salvage with a custom prosthetic knee replacement after resection of a malignant tumor of the distal part of the femur yielded satisfactory overall results and relatively good functional outcomes, although revision was necessary in 43% of patients [141].

Instability: Reconstruction with an osteoarticular allograft after intra-articular resection of the proximal aspect of the humerus has an extremely high rate of complications, including joint instability, fracture of the allograft, and infection [132]. Combined reconstruction with looped allograft and hardware C-C fixation for acromioclavicular joint instability carries the lowest failure rate when controlling for multiple other factors [22]. Severe complications after graft reconstruction for anterior sternoclavicular joint instability are rare, with revision rates as low as 5% [129].

Periprosthetic Fracture / Structural Failure: Substantially higher complication rates were observed in autograft and weave cohorts for distal biceps tendon reconstruction, with more than half of autograft-related complications associated with donor site morbidity [136]. Vascularized fibula autograft reconstruction after intercalary resection of the humerus for primary bone tumors is complex, with frequent complications in the first years, but provides long-term durable outcomes [2].

Nerve Palsy: Long-term outcomes of spinal accessory nerve transfer to the musculocutaneous nerve in birth brachial palsy have yet to be fully demonstrated [134].

Other Considerations: Direct repair, autograft reconstruction, or allograft reconstruction for chronic distal biceps tendon ruptures are viable treatment options with similar outcomes [1]. Revision reattachment of the distal biceps tendon results in acceptable functional outcomes [4]. The complication rate for primary repair of chronic distal biceps tendon tears may be higher than that for early repair [23]. Ulnar collateral ligament reconstruction (UCLR) provides excellent patient-reported and clinical outcomes at medium-term follow-up with low complication and revision rates [123]. The incidence of primary UCL reconstructions among professional pitchers is increasing, while the rate of primary reconstructions requiring revision is decreasing [124]. UCL repair is associated with a significantly higher risk of revision UCL surgery than UCL reconstruction in a national sample [128]. Allografts may be comparable to autografts for crucial effectiveness outcomes in posterior cruciate ligament reconstruction, but insufficient evidence exists to judge crucial safety outcomes due to poor reporting [126]. Complications after osteochondral graft reconstruction for capitellar osteochondritis dissecans lesions are relatively uncommon, and donor-site morbidity is low [120]. The overall complication rate for scapulothoracic fusion in facioscapulohumeral muscular dystrophy is high (41%), requiring cautious patient selection after consideration of nonsurgical treatment [121]. Autologous bone graft is effective for the treatment of post-traumatic bone defects [122]. When patients sustaining terrible triad injuries require secondary surgeries for complications, their ultimate functional outcome scores worsen [127]. Complications are very common in terrible triad injuries of the elbow, with over 25% of patients requiring revision surgery [131]. Patients treated with an external fixator (ExF) or internal joint stabilizer (IJS) for unstable elbow injuries had similar clinical outcomes, but complications and second surgeries were more likely in ExF patients [130]. The complication rate for Coonrad-Morrey total elbow replacement can be high, and recognition of technical problems might lead to reduction of the complication and revision rate [140]. Revision surgery for cubital tunnel syndrome should be offered for persistent or recurrent symptoms unexplained by alternative diagnosis, but complete resolution of symptoms is unlikely [15].

Recovery

Light activity (weeks): Return to desk work and light activities of daily living occurs rapidly for many upper extremity procedures. Approximately 93% of patients who underwent distal triceps repair returned to work by 2.2 ± 3.2 months postoperatively [76]. For distal biceps repairs, modified two-incision techniques and Endobutton repairs allow for safe immediate active range of motion protocols with early return of nearly full range of motion and strength [47, 54].

Full activity (months): Return to sport and manual labor timelines vary significantly by procedure and patient population. Rehabilitation protocols for ulnar collateral ligament (UCL) repair with suture tape augmentation are structured around a 5-phase program with return to sport approaching 20 weeks [37]. In professional baseball pitchers, return to play after revision Tommy John surgery is much lower than after primary reconstruction [89]. Control pitchers who do not require revision UCL reconstruction pitch significantly less, below their pre–primary UCL reconstruction workload [74]. Conversely, Major League Baseball pitchers who require revision UCL reconstruction after returning to play following primary UCL reconstruction pitch at or above their pre–primary UCL reconstruction workload [74].

Complete recovery / outcome plateau (months): Functional outcomes stabilize over extended periods. Clinical and functional outcomes at more than 1 year after distal biceps tendon repair were excellent in both bioabsorbable and nonabsorbable screw groups [116]. Revascularization of the fascia lata following shoulder superior capsule reconstruction plateaus at 12 months postoperation [114]. Females demonstrated favorable clinical outcomes at a mean follow-up of 6 years after operative management of posterolateral rotatory instability, with the majority of elbows returning to a preinjury level of function and sport, regardless of whether they underwent primary or revision surgery [112].

Rehabilitation protocol: Rehabilitation strategies must be tailored to the specific reconstruction. Successful surgical reconstruction of the elbow medial ulnar collateral ligament requires a thorough rehabilitation program for a good outcome [8]. Primary repair of distal triceps tendon ruptures yields good, durable patient outcomes with minimal rerupture regardless of whether transosseous bone tunnels or suture anchor constructs are used [17]. Primary repair of the distal triceps tendon is possible when performed within 12 weeks after injury [38].

Functional milestones: Outcomes are generally favorable for acute repairs and specific chronic reconstructions. Direct repair, autograft reconstruction, and allograft reconstruction for chronic distal biceps tendon ruptures yield similar outcomes [1]. Direct repair is the preferred treatment for chronic distal biceps tendon ruptures when possible [9]. Autologous tendon graft reconstruction results in predictably good outcomes for chronic distal biceps tendon ruptures when direct repair is not possible [9]. Revision distal biceps tendon reattachment results in acceptable functional outcomes [4]. Surgical repair of an isolated rupture of the separate insertion of the short head of the biceps on the radial tuberosity offers a good prognosis for functional recovery, including full strength and return to sporting activities [11]. Treatment of adult brachial plexus injuries within 6 months yields favorable outcomes for the restoration of essential shoulder and elbow function [41]. Free functional muscle transfer is a powerful tool for addressing deficits in both primary and delayed settings of adult brachial plexus injuries [41].

Other Considerations: Several factors influence long-term durability and return-to-play metrics. The complication rate for primary repair of chronic distal biceps tendon tears may be higher than that for early repair [23]. Dropout rates are high among European athletes even after successful ulnar collateral ligament reconstruction using the interference screw technique and triceps fascia autograft [113]. The overall rate of return to pre-injury pitch workload following revision UCL reconstruction is low among professional pitchers [80]. Overall durability decreases significantly after revision Tommy John surgery compared with controls [89]. UCL repair can be considered as an option in the right type of injury for professional baseball players hoping to maximize performance after surgery with minimal recovery time [115]. Despite the restoration of a normal patellar height following reconstruction of chronic patellar tendon rupture with contralateral bone-tendon-bone autograft, function did not return to preinjury level [119].

Key Evidence

• [L1] Currently, available evidence suggests that direct repair, autograft reconstruction, or allograft reconstruction are all viable treatment options with similar outcomes. (10.1016/j.xrrt.2022.02.007)
• [L4] These are complex procedures that should be performed by an experienced team, as complications may occur frequently in the first years, but successful reconstruction provides a long-term, durable outcome with excellent functional results. (10.1097/corr.0000000000002739)
• [L5] Advances in preoperative evaluation and surgical reconstruction have improved functional outcomes. (10.5435/00124635-200301000-00007)
• [L4] Revision reattachment resulted in acceptable functional outcomes. (10.1016/j.jhsa.2019.05.006)
• [L4] The reconstruction technique using a human extracellular matrix scaffold can be expected to yield a strong repair and successful outcomes. (10.1016/j.jse.2013.06.021)
• [L4] They present acutely, have a poor natural history akin to complete tears, and have good outcomes with acute and delayed reconstruction. (10.1016/j.jse.2020.04.038)
• [L4] If this reduction is not possible, then other surgical reconstruction should be considered. (10.2106/jbjs.15.00832)
• [L4] A good outcome depends on successful surgical reconstruction followed by a thorough rehabilitation program. (10.1016/j.jse.2010.01.005)
• [L3] This suggests that when possible direct repair is preferred, however, if not possible, reconstruction with an autologous tendon graft results in predictably good outcomes. (10.1016/j.jse.2019.01.006)
• [L5] Treatment of UCL injuries depends on the type of tear, with nonoperative management for low-grade partial tears and UCL reconstruction as the gold standard for complete tears. (10.1016/j.arthro.2020.02.022)
• [L4] Surgical repair can offer a good prognosis for functional recovery, including full strength and return to sporting activities. (10.1111/sae.12019)
• [Commentary] The article provides good guidelines for the management of complex shoulder reconstruction cases, noting that surgery should be performed at 1 year old or younger as referrals are occurring too late for the best results. (10.1177/1753193412460137)
• [L5] Although incomplete tears may be managed nonsurgically, complete ruptures are best treated with early surgical repair. (10.5435/00124635-200305000-00006)
• [L4] A contemporary injury classification system is proposed that includes injury timing, injury location, and standardized terminology addressing tear extent to more accurately reflect the musculotendinous morphology of PM injuries and better inform surgical management, rehabilitation, and research. (10.1016/j.jse.2011.04.035)
• [L3] Revision surgery can be offered in the setting of persistent or recurrent symptoms that are unexplained by an alternative diagnosis, but patients should be counseled that complete resolution of symptoms is unlikely. (10.1016/j.jhsa.2014.07.013)
• [L5] Reconstructive options are detailed to serve as a framework for the treating surgeon in these complex cases. (10.5435/jaaos-d-17-00158)
• [L3] Primary repair of distal triceps tendon ruptures yields good, durable patient outcomes with minimal rerupture regardless of repair construct. (10.1016/j.jse.2017.08.006)
• [L4] It should be considered a viable adjunct treatment and part of a comprehensive reconstructive plan. (10.1016/j.jhsa.2012.10.039)
• [L3] The frequency of infections in the cohort was similar to previously reported series, with no differences found between the different reconstruction techniques. (10.1016/j.jse.2016.10.014)
• [L5] Biologic reconstructions with viable bone autograft can provide more durable long-term reconstructions and growing reconstructions in the pediatric population at the expense of high short-term complication rates and donor-site morbidity. (10.5435/jaaos-d-25-00228)
• [L4] The results of this series do not support the strong recommendations of other authors to use vascularized nerve grafts in the reconstruction of large nerve defects. (10.1016/j.jhsa.2009.08.004)
• [L3] Combined reconstruction with looped allograft and hardware C-C fixation carried the lowest failure rate when controlling for multiple other factors. (10.1016/j.jse.2014.06.016)
• [L4] However, the complication rate may be higher than early repair. (10.1177/15589447221107691)
• [L4] Our method optimizes the approach to direct repair using the most secure fixation method and allows anatomic repair without loss of range movement or function. (10.1016/j.jse.2012.01.012)
• [L3] In delayed cases, a positive test may predict the need for graft reconstruction. (10.1177/1758573219847146)
• [Paper] With the recent advancements in microsurgical techniques, harvesting flaps in a free-style manner have become a practical reality. (10.1016/j.injury.2008.05.020)
• [L4] The surgical technique is simple; it does not need a graft, nor does it present major complications, and material extraction is unnecessary. (10.1016/j.jseint.2020.04.014)
• [L4] These injuries typically resolve within 3 months, and at the latest, 5 months after surgery. (10.1016/j.jse.2012.08.001)
• [L4] Overall interposition graft repairs have shown some promising 2-year outcomes in patient and physician-reported functional outcomes, regardless of graft type. (10.5435/jaaos-d-19-00500)
• [L4] Due to heterogeneity in rupture patterns, surgical procedures, and outcome measures, it is difficult to ascertain the superiority of one surgical technique over another. (10.1016/j.jse.2021.06.019)
• [L3] However, additional studies are required to define and refine this surgical technique. (10.1177/1558944717735944)
• [L4] Subscapularis transfer is a useful adjunct in the operative treatment of massive tears of the rotator cuff; it facilitates the closure of larger defects that are not amenable to simpler, more traditional reconstructive techniques. (10.2106/00004623-199602000-00011)
• [L4] This method should be considered for the treatment of complicated cases in young adults, as it provides a very good functional outcome even in delayed tendon repairs complicated by infection. (10.1007/s00167-013-2544-6)
• [Case_report] If anatomical and technical considerations are respected, such as preserving the outer table and reconstructing the defect, the patient could be spared this inconvenience. (10.1016/j.otsr.2011.03.026)
• [L4] By combining an understanding of anatomy and biomechanics with surgical technique, the authors could reconstruct chronically dislocated joints to achieve functional and painless elbows. (10.1016/j.jse.2006.09.003)
• [L4] Rehabilitation protocols for UCL repair with suture tape augmentation were often structured around a 5-phase program with RTS approaching 20 weeks. (10.1016/j.xrrt.2024.07.005)
• [Abstract] Primary repair of the ruptured tendon was possible when performed within 12 weeks after the injury. (10.1016/j.jse.2014.11.027)
• [L5] Dynamic analyses using a 3-dimensional elbow model showed that none of the configurations for double-strand LUCL reconstruction were isometric. (10.1016/j.jse.2018.11.070)
• [L4] Although it provides a stable platform for elbow and hand function, actual shoulder function is limited. (10.1016/j.jse.2008.10.011)
• [L5] When treated within 6 months, outcomes are favorable for the restoration of essential shoulder and elbow function, though free functional muscle transfer is a powerful tool for addressing deficits in both primary and delayed settings. (10.1016/j.jhsa.2021.05.008)
• [L4] Augmentation and reconstruction procedures are grossly equivalent, but more data examining the long-term functional status, recovery to preinjury daily and sport activities and occurrence of degenerative changes are needed. (10.1007/s00167-013-2418-y)
• [L5] Ulnar collateral ligament reconstruction using a suspension button fixation technique reliably restored elbow kinematics to the intact state. (10.1177/0363546509350109)
• [L4] The primary goal for a functional upper extremity is to restore the function of the hand, and the timing of total elbow arthroplasty must take into account the status of all joints. (10.2106/jbjs.03031pp)
• [L4] In this athletic population, anterior cruciate ligament primary repair in acute incomplete lesion combined with bone marrow stimulation effectively restored knee stability and function. (10.1177/0363546508327141)
• [L4] A modified 2-incision distal biceps repair allows a safe immediate active range of motion protocol with early return of nearly full range of motion and strength, without any clinically significant disability. (10.1177/0363546508323749)
• [L3] An improvement in isometric contraction in flexion of the elbow was observed, but this did not reach the flexion power of the contralateral healthy arm. (10.1007/s00167-018-5007-2)
• [L4] However, the available current evidence possesses a high degree of fragility, and further studies are needed with objective measurements to determine the optimal elbow flexion angle for graft fixation. (10.1016/j.jse.2018.07.029)
• [L4] The indication for this type of treatment must be selected and narrowed down, as it is a salvage procedure, and any failure would cause even more complex situations. (10.1186/s13018-023-04465-2)
• [L4] Its presence should be considered in patients in whom there is a mechanical block to function after injury to the elbow or surgery. (10.1016/j.jse.2007.06.018)
• [L5] When prevention fails, nonoperative followed by operative treatment modalities can be pursued. (10.1016/j.jhsa.2009.02.020)
• [L5] Both procedures alter normal joint kinematics by shifting the humeral head apex posteriorly in external rotation. (10.1007/s00167-015-3885-0)
• [L4] This repair type has documented recovery of both strength and endurance with high patient satisfaction, including return to work and avocational activities. (10.1016/j.jhsa.2009.05.021)
• [L4] The treatment resulted in significant gains in elbow motion and upper extremity function with few complications. (10.1016/j.jse.2010.05.029)
• [L5] The 4-category classification was reproducible within and between reviewers. (10.1016/j.jse.2024.02.030)
• [L4] The authors suggest that the approach allows better visualization of the lateral structures for repair and confers excellent stability to the elbow joint. (10.1016/j.jseint.2021.11.011)
• [L4] Following UCL repairs and reconstructions, elbow ROM is reliably preserved or improved with a predictable trajectory of rapid improvement within the first 2 to four months. (10.1016/j.jse.2025.10.002)
• [L4] It is a safe and predictable technique for reconstruction of the UCL. (10.1177/0363546506289884)
• [L4] Improved, but not normal, elbow motion can be expected in many but not all cases. (10.2106/00004623-200203000-00008)
• [L4] The procedure demonstrated significant improvements in elbow function and muscle strength without postoperative weakness in elbow flexion. (10.1016/j.jse.2025.10.007)
• [L4] The data suggest that elbow range of motion and functional use are maintained from comparison with short-term studies. (10.1016/j.jse.2016.09.057)
• [L4] PLRI of the elbow remains to be fully understood. (10.1016/j.arthro.2014.02.029)
• [L5] Several techniques are often combined in a single stage to provide an improved elbow position in patients with and without volitional control of their affected extremities. (10.1016/j.jhsa.2023.09.015)
• [L5] Capsular repair also significantly alters normal glenohumeral kinematics. (10.1007/s00167-015-3915-y)
• [L4] It provides good elbow function and, being a biological reconstruction option using native bone, is likely to provide long-term stability and durability. (10.1302/0301-620x.106b11.bjj-2024-0337.r1)
• [L5] Thus, it should be considered in the development of improved repair techniques for stabilizers of the elbow. (10.1186/s12891-018-2341-y)
• [L4] This procedure should be considered for this unique patient population due to its improved pain relief and low morbidity. (10.1177/15589447211072218)
• [L3] The use of a method of reconstruction that is appropriate with regard to the needs of the patient and preoperative counseling regarding the expected functional level and restrictions of activity are critical for a high level of postoperative satisfaction. (10.2106/00004623-199612000-00011)
• [L3] MLB pitchers who require revision UCL reconstruction after returning to play following primary UCL reconstruction pitch at or above their pre–primary UCL reconstruction workload, whereas control pitchers who do not require revision pitch significantly less, below their pre–primary UCL reconstruction workload. (10.1016/j.jse.2016.11.045)
• [L4] The technique produces high levels of subjective satisfaction with regard to pain relief, function, and stability. (10.2106/00004623-200003000-00008)
• [L4] Approximately 93% of patients who underwent distal triceps repair returned to work by 2.2 ± 3.2 months postoperatively. (10.1016/j.jse.2020.07.036)
• [L4] All reported surgical procedures demonstrate reduction in pain the best results from the Eden-Lange muscle transfer. (10.1177/1758573219872730)
• [L4] Outcomes vary, with some studies showing good stability and pain relief, while others note unpredictable results or donor site morbidity. (10.1111/j.1758-5740.2012.00215.x)
• [L4] The overall rate of return to pre-injury pitch workload following revision UCL reconstruction is low among professional pitchers. (10.1016/j.jse.2013.01.031)
• [L5] Nonoperative management is feasible for elderly, low-demand patients, while repair of chronic tears should be reserved for younger, healthier patients with high functional demands. (10.5397/cise.2023.00129)
• [L4] Allograft reconstruction is a useful technique for chronic pectoralis major ruptures where direct repair is not possible, allowing patients to return to preinjury occupation levels. (10.1177/1758573217741319)
• [L4] Careful postoperative management can help achieve positive functional outcomes. (10.1016/j.jse.2014.09.028)
• [L3] Surgery remains an effective option for treatment failures with no detrimental effects from prior conservative management. (10.1016/j.jse.2025.04.017)
• [L1] Clinically, suture button fixation demonstrated similar functional outcome and range of motion when compared with screw fixation, with the potential benefit of lower rates of graft resorption and hardware-related complications. (10.1016/j.arthro.2023.10.021)
• [L4] The surgical technique provides excellent initial fixation without metal fixators and enables aggressive therapeutic exercise and early return to sports. (10.1016/j.arthro.2006.09.006)
• [L3] For MLB pitchers, return to play after revision surgery is much lower than after primary reconstruction, and overall durability decreases significantly compared with controls. (10.1016/j.jse.2015.08.040)
• [L5] Further clinical research is necessary to determine whether the suggested technique will result in superior results for patient function or pain relief. (10.1016/j.jse.2007.03.030)
• [L3] Treatment can significantly improve patient-oriented outcomes, but final clinical outcomes remain guarded, and many patients have persistent pain regardless of the transfer technique selected. (10.1016/j.jse.2014.12.014)
• [L4] MRI grading of UCL injuries can help predict return to play and the need for surgery. (10.1177/0363546515621756)
• [Case_report] This appears to be a reasonable method to salvage this difficult and challenging problem when nonsurgical management has failed to provide relief. (10.1016/j.jse.2011.08.043)
• [L3] After reconstructive shoulder surgery particular attention should be paid to prevention of complications, excellent perioperative pain control and restoration of abduction during rehabilitation. (10.1186/s12891-017-1812-x)
• [L4] At a minimum 5-year follow-up, patients with successful non-operative treatment for type III-V ACJ injuries achieved similar clinical outcomes compared to those who were converted to ACCR. (10.1007/s00167-020-06159-2)
• [L4] Graft host nonunion is a common mode of failure and remains a concern in this type of prosthesis. (10.1016/j.jse.2024.02.037)
• [L4] LUCL reconstruction using the docking technique facilitates simple graft tensioning and excellent graft fixation. (10.1016/j.jse.2011.04.033)
• [L1] Non-rigid fixation resulted in adequate bone graft healing and osseous incorporation. (10.1177/1758573219872512)
• [L5] Graft fixation techniques should be chosen with respect to the preoperative type of instability. (10.1016/j.arthro.2012.08.026)
• [L5] All-suture anchors offer benefits such as smaller size and bone preservation but require careful deployment to prevent gap formation and may be weakened by decortication. (10.5435/jaaos-d-20-01224)
• [L4] Treatment includes reconstruction of the soft-tissue envelope, revision of prosthetic components, and possibly the use of allografts. (10.2106/00004623-199901000-00006)
• [L3] Surgical repair with plate fixation and bone grafting achieves high union rates with few complications. (10.1016/j.jse.2017.06.040)
• [L4] Females demonstrated favorable clinical outcomes at a mean follow-up of 6 years, with a majority of elbows returning to a preinjury level of function and sport, regardless of whether they underwent primary or revision surgery. (10.1016/j.jse.2025.08.025)
• [L4] However, the dropout, even after successful reconstruction in European athletes, is high. (10.1016/j.jse.2012.07.010)
• [L4] Revascularization of the fascia lata was dependent on the location of the fascia lata and plateaus at 12 months postoperation. (10.1186/s13018-022-03375-z)
• [L4] Repair can be considered as an option in the right type of injury for players hoping to maximize performance after surgery with minimal recovery time. (10.5397/cise.2023.01109)
• [L3] Clinical and functional outcome at more than 1 year after distal biceps tendon repair was excellent in both groups. (10.1016/j.jse.2015.12.007)
• [L3] Two-stage reimplantation for deep PJI following total elbow arthroplasty resulted in infection eradication in 69% of cases, with 31% considered treatment failures secondary to recurrent infection. (10.1016/j.jse.2022.01.064)
• [L4] Limb salvage with intact motor function was achieved in 100% of cases, though reconstruction survival was 28.6% and complication rates were high. (10.1186/s13018-025-05956-0)
• [L4] However, despite the restoration of a normal patellar height, function did not return to preinjury level. (10.1007/s00167-015-3951-7)
• [L4] Complications are relatively uncommon, and donor-site morbidity is low. (10.1016/j.arthro.2020.01.037)
• [L1] The overall complication rate is high (41%), and patients must be selected for surgery with caution after consideration of nonsurgical treatment. (10.1177/1758573219866195)
• [L1] The results of this meta-analysis demonstrate the effectiveness of autologous graft for bone defects. (10.1186/s12891-016-1312-4)
• [L4] UCLR provides excellent patient-reported and clinical outcomes to patients at medium-term follow-up with low complication and revision rates. (10.1136/jisakos-2021-000614)
• [L4] The incidence of primary UCL reconstructions among professional pitchers is increasing; however, the rate of primary reconstructions requiring revision is decreasing. (10.1016/j.jhsa.2015.07.024)
• [L4] Infection developed in 11.7 per cent of patients with massive allografts, with no significant differences in age, graft type, or site between infected and non-infected groups. (10.2106/00004623-198870090-00032)
• [L1] Allografts may be comparable to autografts for crucial effectiveness outcomes, but insufficient evidence was found to judge crucial safety outcomes due to poor reporting of safety measures and outcomes. (10.1016/j.asmr.2020.07.017)
• [L4] When patients sustain complications that require secondary surgeries, their ultimate functional outcome scores worsen. (10.1016/j.jhsa.2023.04.003)
• [L3] UCL repair was associated with a significantly higher risk of revision UCL surgery than UCL reconstruction in a national sample. (10.1016/j.arthro.2024.10.049)
• [L4] Severe complications were rare and revision rates were as low as 5%. (10.1007/s00167-015-3770-x)
• [L3] Patients treated with an ExF or IJS had similar clinical outcomes, but complications and second surgeries were more likely in ExF patients. (10.1016/j.jseint.2023.03.006)
• [L4] There was an extremely high rate of complications, including joint instability, fracture of the allograft, and infection, leading the authors to no longer routinely perform this reconstruction. (10.2106/00004623-199908000-00009)
• [Abstract] Two-stage reimplantation for PJI after TEA was successful in eradicating deep infection in 36 elbows (69%). (10.1016/j.jse.2022.01.066)
• [L4] However, long-term outcomes of this procedure have yet to be fully demonstrated. (10.1016/j.jhsa.2024.04.017)
• [L4] The revision rate for UCLR with allograft appears to be greater compared to UCLR with autograft, although this may be secondary to limited allograft literature. (10.1016/j.jse.2023.10.023)
• [L1] However, substantially higher complication rates were observed in the autograft and weave cohorts; more than half of the complications related to the use of autograft were associated with donor site morbidity. (10.1016/j.jseint.2020.09.010)
• [L4] Both grafts demonstrate high rates of complications and failures at minimum 2-year follow-up. (10.1016/j.arthro.2023.01.003)
• [L3] One-stage revision arthroplasty with complete removal and reimplantation for periprosthetic shoulder infection results in lower reoperation rates for infection and similar clinical outcomes compared to one-stage component exchange and two-stage revision in our series. (10.1016/j.jse.2016.07.064)
• [L4] It is a 1-stage procedure with no morbidity to the harvest site that provides stable and adequate coverage even in cases with postoperative infection. (10.1016/j.jse.2019.03.020)
• [L4] The complication rate can be high, and recognition of technical problems might lead to reduction of the complication and revision rate. (10.1016/j.jse.2006.01.013)
• [L3] Limb salvage with a custom prosthetic knee replacement yielded satisfactory overall results and relatively good functional outcomes at medium to long-term follow-up, although revision was necessary in 43 percent of patients. (10.2106/00004623-199805000-00004)

See Also

• Elbow Instability
• Distal Biceps Rupture
• Distal Biceps Repair
• Cubital Tunnel Syndrome
• Patient Outcomes
• Surgical Procedures
• Elbow Arthroplasty

References

[1] Outcomes and complications after different surgical techniques for the treatment of chronic distal biceps tendon ruptures: a systematic review and quantitative synthesis. JSES Reviews, Reports, and Techniques. 2022. DOI: 10.1016/j.xrrt.2022.02.007

[2] Are Vascularized Fibula Autografts a Long-lasting Reconstruction After Intercalary Resection of the Humerus for Primary Bone Tumors?. Clinical Orthopaedics & Related Research. 2023. DOI: 10.1097/corr.0000000000002739

[3] Advances in the Management of Humeral Nonunion. Journal of the American Academy of Orthopaedic Surgeons. 2003. DOI: 10.5435/00124635-200301000-00007

[4] Diagnosis, Etiology and Outcomes of Revision Distal Biceps Tendon Reattachment. The Journal of Hand Surgery. 2020. DOI: 10.1016/j.jhsa.2019.05.006

[5] Dermal allograft reconstruction of a chronic pectoralis major tear. Journal of Shoulder and Elbow Surgery. 2013. DOI: 10.1016/j.jse.2013.06.021

[6] Distal biceps short head tears: repair, reconstruction, and systematic review. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2020.04.038

[7] The Effectiveness of the Latarjet Procedure in Patients with Chronic Locked Anterior Shoulder Dislocation. Journal of Bone and Joint Surgery. 2016. DOI: 10.2106/jbjs.15.00832

[8] Elbow medial ulnar collateral ligament reconstruction: Clinical relevance and the docking technique. Journal of Shoulder and Elbow Surgery. 2010. DOI: 10.1016/j.jse.2010.01.005

[9] Management of chronic distal biceps tendon ruptures: primary repair vs. semitendinosus autograft reconstruction. Journal of Shoulder and Elbow Surgery. 2019. DOI: 10.1016/j.jse.2019.01.006

[10] Elbow Ulnar Collateral Ligament Injuries: Indications, Management, and Outcomes. Arthroscopy. 2020. DOI: 10.1016/j.arthro.2020.02.022

[11] Isolated Rupture of the Separate Insertion of the Short Head of Biceps on the Radial Tuberosity: Ultrasound and Magnetic Resonance Imaging Diagnosis with Successful Surgical Treatment. Shoulder & Elbow. 2013. DOI: 10.1111/sae.12019

[12] Commentary on Sibinski et al. Management strategies for shoulder reconstruction in obstetric brachial plexus injury with special reference to loss of internal rotation after surgery. Journal of Hand Surgery (European Volume). 2012. DOI: 10.1177/1753193412460137

[13] Quadriceps Tendon Rupture. Journal of the American Academy of Orthopaedic Surgeons. 2003. DOI: 10.5435/00124635-200305000-00006

[14] A systematic review and comprehensive classification of pectoralis major tears. Journal of Shoulder and Elbow Surgery. 2012. DOI: 10.1016/j.jse.2011.04.035

[15] Outcomes of Revision Surgery for Cubital Tunnel Syndrome. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.07.013

[16] Chronic Achilles Ruptures: Reconstructive Options. Journal of the American Academy of Orthopaedic Surgeons. 2018. DOI: 10.5435/jaaos-d-17-00158

[17] Functional outcomes of distal triceps tendon repair comparing transosseous bone tunnels with suture anchor constructs. Journal of Shoulder and Elbow Surgery. 2017. DOI: 10.1016/j.jse.2017.08.006

[18] Neurotization to Innervate the Deltoid and Biceps: 3 Cases. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2012.10.039

[19] Factors associated with infection after reconstructive shoulder surgery for proximal humerus tumors. Journal of Shoulder and Elbow Surgery. 2017. DOI: 10.1016/j.jse.2016.10.014

[20] Autograft and Biologic Living Bone Reconstructions in Orthopaedic Oncology. Journal of the American Academy of Orthopaedic Surgeons. 2025. DOI: 10.5435/jaaos-d-25-00228

[21] Results of C5 Root Grafting to the Musculocutaneous Nerve Using Pedicled, Vascularized Ulnar Nerve Grafts. The Journal of Hand Surgery. 2009. DOI: 10.1016/j.jhsa.2009.08.004

[22] Short-term Failure Rates after Acromio-Clavicular Joint Reconstruction: A Comparison of Anatomic and Non-Anatomic Surgical Techniques. Journal of Shoulder and Elbow Surgery. 2014. DOI: 10.1016/j.jse.2014.06.016

[23] Primary Repair of Chronic Distal Biceps Tendon Tears. HAND. 2022. DOI: 10.1177/15589447221107691

[24] Anatomic direct repair of chronic distal biceps brachii tendon rupture without interposition graft. Journal of Shoulder and Elbow Surgery. 2012. DOI: 10.1016/j.jse.2012.01.012

[25] Distal biceps hook test – Sensitivity in acute and chronic tears and ability to predict the need for graft reconstruction. Shoulder & Elbow. 2019. DOI: 10.1177/1758573219847146

[26] Free-style free flap. Injury. 2008. DOI: 10.1016/j.injury.2008.05.020

[28] Chronic acromioclavicular dislocations: multidirectional stabilization without grafting. JSES International. 2020. DOI: 10.1016/j.jseint.2020.04.014

[29] Prognosis for recovery of posterior interosseous nerve palsy after distal biceps repair. Journal of Shoulder and Elbow Surgery. 2013. DOI: 10.1016/j.jse.2012.08.001

[30] Interposition Graft Repair of Irreparable Rotator Cuff Tears: A Review of Biomechanics and Clinical Outcomes. Journal of the American Academy of Orthopaedic Surgeons. 2020. DOI: 10.5435/jaaos-d-19-00500

[31] The surgical management of distal triceps tendon ruptures: a systematic review. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2021.06.019

[32] Lower Trapezius Transfer for Patients With Brachial Plexus Injury. HAND. 2017. DOI: 10.1177/1558944717735944

[33] Subscapularis Transfer for Reconstruction of Massive Tears of the Rotator Cuff†. The Journal of Bone & Joint Surgery*. 1996. DOI: 10.2106/00004623-199602000-00011

[34] Traumatic tibialis anterior tendon rupture: treatment with a two‐stage silicone tube and an interposition hamstring tendons graft protocol. Knee Surgery, Sports Traumatology, Arthroscopy. 2013. DOI: 10.1007/s00167-013-2544-6

[35] Iliac wing fracture following graft harvesting from the anterior iliac crest: Literature review based on a case report. Orthopaedics & Traumatology: Surgery & Research. 2012. DOI: 10.1016/j.otsr.2011.03.026

[36] Treatment of chronically dislocated elbows: A report of three cases. Journal of Shoulder and Elbow Surgery. 2007. DOI: 10.1016/j.jse.2006.09.003

[37] Variability of rehabilitation protocols for ulnar collateral ligament repair with suture tape augmentation. JSES Reviews, Reports, and Techniques. 2024. DOI: 10.1016/j.xrrt.2024.07.005

[38] Surgical Treatment of 150 Acute Distal Triceps Tendon Ruptures. Journal of Shoulder and Elbow Surgery. 2015. DOI: 10.1016/j.jse.2014.11.027

[39] Three-dimensional computed tomography modeling for kinematic analysis of double-strand lateral ulnar collateral ligament reconstruction. Journal of Shoulder and Elbow Surgery. 2019. DOI: 10.1016/j.jse.2018.11.070

[40] Functional outcome following endoprosthetic reconstruction of the proximal humerus. Journal of Shoulder and Elbow Surgery. 2009. DOI: 10.1016/j.jse.2008.10.011

[41] Management of Adult Brachial Plexus Injuries. The Journal of Hand Surgery. 2021. DOI: 10.1016/j.jhsa.2021.05.008

[42] Augmentation or reconstruction of PCL? A quantitative review. Knee Surgery, Sports Traumatology, Arthroscopy. 2013. DOI: 10.1007/s00167-013-2418-y

[44] Revision Ulnar Collateral Ligament Reconstruction Using a Suspension Button Fixation Technique. The American Journal of Sports Medicine. 2009. DOI: 10.1177/0363546509350109

[45] Total Elbow Arthroplasty After Interposition Arthroplasty for Elbow Arthritis. The Journal of Bone & Joint Surgery. 2005. DOI: 10.2106/jbjs.03031pp

[46] Primary Repair Combined with Bone Marrow Stimulation in Acute Anterior Cruciate Ligament Lesions. The American Journal of Sports Medicine. 2009. DOI: 10.1177/0363546508327141

[47] Immediate Active Range of Motion after Modified 2-Incision Repair in Acute Distal Biceps Tendon Rupture. The American Journal of Sports Medicine. 2008. DOI: 10.1177/0363546508323749

[48] Increased fatigue of the biceps after tenotomy of the long head of biceps tendon. Knee Surgery, Sports Traumatology, Arthroscopy. 2018. DOI: 10.1007/s00167-018-5007-2

[49] Elbow flexion angle during graft fixation for ulnar collateral ligament reconstruction: a systematic review of outcomes and complications. Journal of Shoulder and Elbow Surgery. 2018. DOI: 10.1016/j.jse.2018.07.029

[50] Megaprosthetic replacement in complex distal humerus fractures in elderly patients: a case series. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-023-04465-2

[51] Heterotopic ossification after the Outerbridge-Kashiwagi procedure in the elbow. Journal of Shoulder and Elbow Surgery. 2008. DOI: 10.1016/j.jse.2007.06.018

[52] Prevention and Treatment of Elbow Stiffness. The Journal of Hand Surgery. 2009. DOI: 10.1016/j.jhsa.2009.02.020

[53] Biomechanical comparison of the Latarjet procedure with and without a coracoid bone block. Knee Surgery, Sports Traumatology, Arthroscopy. 2015. DOI: 10.1007/s00167-015-3885-0

[54] Endobutton Repair of Distal Biceps Tendon Ruptures. The Journal of Hand Surgery. 2009. DOI: 10.1016/j.jhsa.2009.05.021

[55] Treatment of heterotopic ossification of the elbow following burn injury: Recommendations for surgical excision and perioperative prophylaxis using radiation therapy. Journal of Shoulder and Elbow Surgery. 2010. DOI: 10.1016/j.jse.2010.05.029

[56] A novel classification of intraoperative ulnar nerve instability to aid transposition surgery. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2024.02.030

[57] Posterior (Boyd) approach to terrible triad injuries. JSES International. 2022. DOI: 10.1016/j.jseint.2021.11.011

[58] Elbow range of motion is stable or improves following ulnar collateral ligament repairs and reconstructions. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2025.10.002

[59] The Modified Docking Procedure for Elbow Ulnar Collateral Ligament Reconstruction. The American Journal of Sports Medicine. 2006. DOI: 10.1177/0363546506289884

[60] OPERATIVE TREATMENT OF ELBOW CONTRACTURE IN PATIENTS TWENTY-ONE YEARS OF AGE OR YOUNGER. The Journal of Bone and Joint Surgery-American Volume. 2002. DOI: 10.2106/00004623-200203000-00008

[61] A preliminary report of lower trapezius muscle transfer for elbow extension in children with brachial plexus birth injury (BPBI). Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2025.10.007

[63] Hemiarthroplasty for the treatment of distal humeral fractures: midterm clinical results. Journal of Shoulder and Elbow Surgery. 2017. DOI: 10.1016/j.jse.2016.09.057

[64] Surgical Treatment of Posterolateral Rotatory Instability of the Elbow. Arthroscopy. 2014. DOI: 10.1016/j.arthro.2014.02.029

[65] Management of the Spastic Elbow Deformity in Adult Patients With Upper Motor Neuron Syndrome. The Journal of Hand Surgery. 2024. DOI: 10.1016/j.jhsa.2023.09.015

[66] Biomechanical comparison of the modified Bristow procedure with and without capsular repair. Knee Surgery, Sports Traumatology, Arthroscopy. 2015. DOI: 10.1007/s00167-015-3915-y

[67] Reconstruction after proximal ulnar resection. The Bone & Joint Journal. 2024. DOI: 10.1302/0301-620x.106b11.bjj-2024-0337.r1

[68] Reattachment of the flexor and extensor tendons at the epicondyle in elbow instability: a biomechanical comparison of techniques. BMC Musculoskeletal Disorders. 2018. DOI: 10.1186/s12891-018-2341-y

[70] Selective Ulnar Nerve Decompression, Capsular Branch Denervation, and Arthroscopic Debridement as a Unique Technique to Improve Quality of Life for Avascular Necrosis of the Distal Humerus and Radius in a Young Patient With ALL. HAND. 2022. DOI: 10.1177/15589447211072218

[71] Limb Salvage for Neoplasms of the Shoulder Girdle. Intermediate Reconstructive and Functional Results. The Journal of Bone & Joint Surgery*. 1996. DOI: 10.2106/00004623-199612000-00011

[74] Relative individual workload changes may be a risk factor for rerupture of ulnar collateral ligament reconstruction. Journal of Shoulder and Elbow Surgery. 2017. DOI: 10.1016/j.jse.2016.11.045

[75] Transfer of the Pectoralis Major Muscle for the Treatment of Irreparable Rupture of the Subscapularis Tendon. The Journal of Bone and Joint Surgery-American Volume*. 2000. DOI: 10.2106/00004623-200003000-00008

[76] Return to work following distal triceps repair. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2020.07.036

[77] Surgical treatment of trapezius palsy: A systematic review. Shoulder & Elbow. 2019. DOI: 10.1177/1758573219872730

[79] Structural Autografts Used in Reconstruction of the Shoulder Joint. Shoulder & Elbow. 2013. DOI: 10.1111/j.1758-5740.2012.00215.x

[80] Functional outcomes following revision ulnar collateral ligament reconstruction in Major League Baseball pitchers. Journal of Shoulder and Elbow Surgery. 2013. DOI: 10.1016/j.jse.2013.01.031

[81] A review of chronic pectoralis major tears: what options are available?. Clinics in Shoulder and Elbow. 2023. DOI: 10.5397/cise.2023.00129

[82] Surgical reconstruction of unrepairable pectoralis major rupture using tendo-achilles allograft. Shoulder & Elbow. 2017. DOI: 10.1177/1758573217741319

[83] Reconstruction of rotator cuff tears in wheelchair-bound paraplegic patients. Journal of Shoulder and Elbow Surgery. 2015. DOI: 10.1016/j.jse.2014.09.028

[84] Efficacy of conservative treatment strategies for partial distal biceps tendon ruptures: a case-control study. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2025.04.017

[85] Suture Button Fixation in Latarjet Has Similar Load to Failure and Clinical Outcomes but Lower Bone Resorption Compared With Screw Fixation: A Systematic Review. Arthroscopy. 2023. DOI: 10.1016/j.arthro.2023.10.021

[87] Acromioclavicular Joint Reconstruction Using Peroneus Brevis Tendon Allograft. Arthroscopy. 2007. DOI: 10.1016/j.arthro.2006.09.006

[89] Outcomes in revision Tommy John surgery in Major League Baseball pitchers. Journal of Shoulder and Elbow Surgery. 2016. DOI: 10.1016/j.jse.2015.08.040

[90] Transfer of segmentally split pectoralis major for the treatment of irreparable rupture of the subscapularis tendon. Journal of Shoulder and Elbow Surgery. 2007. DOI: 10.1016/j.jse.2007.03.030

[92] A comprehensive analysis of pectoralis major transfer for long thoracic nerve palsy. Journal of Shoulder and Elbow Surgery. 2015. DOI: 10.1016/j.jse.2014.12.014

[93] Return-to-Play Outcomes in Professional Baseball Players After Medial Ulnar Collateral Ligament Injuries. The American Journal of Sports Medicine. 2016. DOI: 10.1177/0363546515621756

[94] Treatment of proximal humeral dysplasia epiphysealis hemimelica with custom hemiarthroplasty: a case report. Journal of Shoulder and Elbow Surgery. 2011. DOI: 10.1016/j.jse.2011.08.043

[95] Determinants of patient satisfaction following reconstructive shoulder surgery. BMC Musculoskeletal Disorders. 2017. DOI: 10.1186/s12891-017-1812-x

[96] Conversion to anatomic coracoclavicular ligament reconstruction (ACCR) shows similar clinical outcomes compared to successful non‐operative treatment in chronic primary type III to V acromioclavicular joint injuries. Knee Surgery, Sports Traumatology, Arthroscopy. 2020. DOI: 10.1007/s00167-020-06159-2

[97] Complications and functional outcomes after reconstruction of the proximal humerus with allograft-prosthetic composite: a systematic review of the literature. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2024.02.037

[98] The docking technique for lateral ulnar collateral ligament reconstruction: surgical technique and clinical outcomes. Journal of Shoulder and Elbow Surgery. 2012. DOI: 10.1016/j.jse.2011.04.033

[99] Non-rigid fixation of the glenoid bone block for patients with recurrent anterior instability and major glenoid bone loss: A systematic review. Shoulder & Elbow. 2019. DOI: 10.1177/1758573219872512

[100] Tendon Graft Fixation Sites at the Coracoid Process for Reconstruction of the Coracoclavicular Ligaments: A Kinematic Evaluation of Three Different Surgical Techniques. Arthroscopy. 2013. DOI: 10.1016/j.arthro.2012.08.026

[101] All-Suture Anchors in Orthopaedic Surgery: Design, Rationale, Biomechanical Data, and Clinical Outcomes. Journal of the American Academy of Orthopaedic Surgeons. 2021. DOI: 10.5435/jaaos-d-20-01224

[103] Instability of the Elbow Treated with Semiconstrained Total Elbow Arthroplasty. The Journal of Bone & Joint Surgery*. 1999. DOI: 10.2106/00004623-199901000-00006

[104] Adolescent clavicle nonunions: potential risk factors and surgical management. Journal of Shoulder and Elbow Surgery. 2018. DOI: 10.1016/j.jse.2017.06.040

[112] Operative management of posterolateral rotatory instability in females: favorable 6-year outcomes in primary and revision elbows. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2025.08.025

[113] Long-term results after ulnar collateral ligament reconstruction of the elbow in European athletes with interference screw technique and triceps fascia autograft. Journal of Shoulder and Elbow Surgery. 2012. DOI: 10.1016/j.jse.2012.07.010

[114] Revascularization character of autologous fascia lata graft following shoulder superior capsule reconstruction by enhanced magnetic resonance imaging. Journal of Orthopaedic Surgery and Research. 2022. DOI: 10.1186/s13018-022-03375-z

[115] Ulnar collateral ligament repair in professional baseball players. Clinics in Shoulder and Elbow. 2024. DOI: 10.5397/cise.2023.01109

[116] Distal biceps tendon repair: comparison of clinical and radiological outcome between bioabsorbable and nonabsorbable screws. Journal of Shoulder and Elbow Surgery. 2016. DOI: 10.1016/j.jse.2015.12.007

[117] Does Time Between Trauma And Surgery Affect The Choice Of Surgical Technique And Clinical Results In Distal Biceps Tendon Ruptures?. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2022.01.064

[118] Limb salvage and complication management after (sub-) total humerus resection for primary malignant bone tumors in early childhood. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-05956-0

[119] Reconstruction of chronic patellar tendon rupture with contralateral bone-tendon-bone autograft. Knee Surgery, Sports Traumatology, Arthroscopy. 2015. DOI: 10.1007/s00167-015-3951-7

[120] Capitellar Osteochondritis Dissecans Lesions of the Elbow: A Systematic Review of Osteochondral Graft Reconstruction Options. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2020. DOI: 10.1016/j.arthro.2020.01.037

[121] Outcomes of scapulothoracic fusion in facioscapulohumeral muscular dystrophy: A systematic review. Shoulder & Elbow. 2019. DOI: 10.1177/1758573219866195

[122] Autologous bone graft in the treatment of post-traumatic bone defects: a systematic review and meta-analysis. BMC Musculoskeletal Disorders. 2016. DOI: 10.1186/s12891-016-1312-4

[123] Ulnar collateral ligament reconstruction of the elbow at minimum 48-month mean follow-up demonstrates excellent clinical outcomes with low complication and revision rates: systematic review. Journal of ISAKOS. 2021. DOI: 10.1136/jisakos-2021-000614

[124] Trends in Revision Elbow Ulnar Collateral Ligament Reconstruction in Professional Baseball Pitchers. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2015.07.024

[125] Infection in bone allografts. Incidence, nature, and treatment.. The Journal of Bone & Joint Surgery. 1988. DOI: 10.2106/00004623-198870090-00032

[126] Comparative Effectiveness and Safety of Allografts and Autografts in Posterior Cruciate Ligament Reconstruction Surgery: A Systematic Review. Arthroscopy, Sports Medicine, and Rehabilitation. 2020. DOI: 10.1016/j.asmr.2020.07.017

[127] Short-Term Patient Outcomes After Placement of an Internal Joint Stabilizer for Terrible Triad Injuries: A Multicenter Study. The Journal of Hand Surgery. 2024. DOI: 10.1016/j.jhsa.2023.04.003

[128] Favorable Outcomes Following Elbow Ulnar Collateral Ligament Reconstruction and Repair, Though Repair Associated with Increased Risk of Revision Surgery. Arthroscopy. 2024. DOI: 10.1016/j.arthro.2024.10.049

[129] Outcomes and complications following graft reconstruction for anterior sternoclavicular joint instability. Knee Surgery, Sports Traumatology, Arthroscopy. 2015. DOI: 10.1007/s00167-015-3770-x

[130] Comparison of direct surgical cost and outcomes for unstable elbow injuries: internal joint stabilizer versus external fixation. JSES International. 2023. DOI: 10.1016/j.jseint.2023.03.006

[131] Chapter 93 Terrible Triad Injuries of the Elbow. 2019.

[132] Complications and Functional Outcomes of Reconstruction with an Osteoarticular Allograft After Intra-Articular Resection of the Proximal Aspect of the Humerus. The Journal of Bone and Joint Surgery-American Volume*. 1999. DOI: 10.2106/00004623-199908000-00009

[133] Two-Stage Reimplantation For Deep Infection After Total Elbow Arthroplasty. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2022.01.066

[134] The Outcome of Spinal Accessory Nerve Transfer to the Musculocutaneous Nerve in Birth Brachial Plexus Palsy. The Journal of Hand Surgery. 2025. DOI: 10.1016/j.jhsa.2024.04.017

[135] Graft choice and techniques used in elbow ulnar collateral ligament reconstruction over the last 20 years: a systematic review and meta-analysis. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2023.10.023

[136] Surgical outcomes and complications following distal biceps tendon reconstruction: a systematic review and meta-analysis. JSES International. 2021. DOI: 10.1016/j.jseint.2020.09.010

[137] Acellular Dermal Allograft and Tensor Fascia Lata Autograft Show Similar Patient Outcome Improvement and High Rates of Complications and Failures at a Minimum 2‐Year Follow‐Up: A Systematic Review. Arthroscopy. 2023. DOI: 10.1016/j.arthro.2023.01.003

[138] Periprosthetic shoulder infection: one-stage better than two-stage?. Journal of Shoulder and Elbow Surgery. 2016. DOI: 10.1016/j.jse.2016.07.064

[139] Brachioradialis muscle flap for posterior elbow defects: a simple and effective solution for the upper limb surgeon. Journal of Shoulder and Elbow Surgery. 2019. DOI: 10.1016/j.jse.2019.03.020

[140] Coonrad-Morrey total elbow replacement for primary and revision surgery: A 2- to 7.5-year follow-up study. Journal of Shoulder and Elbow Surgery. 2007. DOI: 10.1016/j.jse.2006.01.013

[141] Prosthetic Knee Replacement after Resection of a Malignant Tumor of the Distal Part of the Femur. Medium to Long-Term Results. The Journal of Bone & Joint Surgery*. 1998. DOI: 10.2106/00004623-199805000-00004