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Abstract

Pathologies of tendon of the long head of the biceps (LHB) are an important cause of shoulder pain. They include tendinopathy, rupture, superior labrum anterior and posterior lesions, pulley tears, and tendon instability. Conservative management of symptomatic LHB tendinopathy is commonly accepted as the first-line treatment. It consists of rest, nonsteroidal anti-inflammatory drugs, corticosteroid injections, and physical therapy. Biceps tenotomy and tenodesis are the most common surgical procedures to manage both isolated LHB pathology and biceps-glenoid complex tears combined with rotator cuff tears. However, controversy persists about the superiority of one of them because there is no evidence of significant differences in functional scores or patient satisfaction between the 2 techniques. This article provides an overview on biomechanical function of the LHB and current strategies for treatment of LHB disorders.
Tendinopathy of the tendon of the long head of
the biceps
Umile Giuseppe Longo * MD, MSc, Mattia Loppini* MD, Gianluca Marineo* MD,
Wasim S Khan **, PhD, Nicola Maffulli MD, MS, PhD, FRCS (Orth) +,
Vincenzo Denaro * MD
* Department of Orthopaedic and Trauma Surgery, Campus Biomedico University, Via
Alvaro del Portillo, 200, 00128 Trigoria Rome, Italy
+ Centre for Sports and Exercise Medicine, Queen Mary University of London, Barts and The
London School of Medicine and Dentistry, Mile End Hospital, 275 Bancroft Road, London
E1 4DG, England
Corresponding author:
Nicola Maffulli MD, MS, PhD, FRCS(Orth)
Centre Lead and Professor of Sports and Exercise Medicine
Consultant Trauma and Orthopaedic Surgeon
Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and
Dentistry
Mile End Hospital, 275 Bancroft Road, London E1 4DG England
Tel: + 44 20 8223 8839 Fax: + 44 20 8223 8930 n.maffulli@qmul.ac.uk
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Abstract
Pathologies of tendon of the long head of the biceps (LHB) are an important cause of
shoulder pain. They include tendinopathy, rupture, SLAP lesions, pulley tears and tendon
instability. Conservative management of symptomatic LHB tendinopathy is commonly
accepted as the first-line treatment. It consists of rest, nonsteroidal anti-inflammatory drugs,
corticosteroid injections and physical therapy. Biceps tenotomy and tenodesis are the most
common surgical procedures to manage both isolated LHB pathology and biceps-glenoid
complex tears combined with rotator cuff tears. However, controversy persists about the
superiority of one of them because there is no evidence of significant differences in
functional scores or patient satisfaction between the two techniques. This article provides an
overview on biomechanical function of the LHB and current strategies for treatment of LHB
disorders.
Key words: Long head of the biceps; Tendinopathy; Rupture; SLAP lesions; Pulley tears and
tendon instability
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Introduction
Shoulder pain is a common cause of pain and occupational disability, with significant impact
on patients’ quality of life, and marked functional impairment 1-4. Pathology of the tendon of
the long head of the biceps (LHB) is an important source of pain in the shoulder, often
causing associated loss of forward flexion. Tendinopathy of the LHB has inflammatory,
degenerative, overuse-related and traumatic causes 5. Although wide research has been
performed on LHB function and disorders, few level I studies have been conducted to guide
physicians in the best management option to adopt in such patients. Biceps tenotomy and
tenodesis are the most common procedures to manage both isolated LHB pathology and
rotator cuff combined with biceps-glenoid complex tears. However, controversy persists
about the superiority of one of them in terms of shoulder stability and motion 6.
This article provides an overview on biomechanical function of the LHB and current
strategies for the management of LHB disorders.
Anatomy
The tendon of the LHB consists of two different portions: intra-articular and extra-articular
tract. The intra-articular portion originates from the supraglenoid tubercle and superior
glenoid labrum. This portion is extrasynovial and passes through glenohumeral joint
anterosuperiorly to the humeral head. The extra-articular portion passes under the pulley and
enters into the bicipital groove. The proximal and distal parts of the tendon of the LHB are
different in term of morphologic features, innervation and vascularization patterns.
The tendon is approximately 5 mm wide and 10 cm long. The intra-articular tract, wide and
flat, is ribbon-shaped, while the extra-articular tract, rounder and smaller, is tubular 7.
The innervation pattern, defined a “net-like pattern” 8, consists of neuronal network
composed of sensory and sympathetic fibers, which are concentrated at the tendon origin and
attenuated at the musculotendinous junction. The blood supply is ensured by branches of the
anterior circumflex humeral artery, particularly at the proximal tract, whereas the distal tract
is relatively avascular. The fibrocartilaginous feature of distal portion of the tendon of the
LHB seems to favour its sliding motion into the groove.
A soft-tissue sling allows the LHB sliding movement maintaining the biceps within its
groove. The tendon can slide up to 18 mm in and out of the glenohumeral joint in forward
flexion and internal rotation 9. Moreover, it turns of 30° to 40° after exit of the joint 10. The
biceps reflection pulley (BRP) consists of coracohumeral ligament fibers, superior
glenohumeral ligament (SGHL), subscapularis and supraspinatus tendon and fibers of
glenohumeral joint capsule. A fibrous expansion from the sternocostal head (falciform
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ligament) envelops the tendon, by attaching to both sides of the bicipital groove 11. These
structures form the anterior reflection pulley of the LHB 12. Also, a posterior pulley of the
LHB has been detected. This structure consists of the large amount of the coracohumeral
ligament fibers which passes behind the LHB and insert at the greater tuberosity, blending to
the anterior fibers of the supraspinatus tendon 13, 14. This anteroposterior capsulo-
ligamentotendinous sling plays an important role stabilizing the distal tract of intra-articular
LHB tendon.
The bicipital groove is a corridor in which the medial wall is higher than the lateral wall. It is
narrowest and deepest at its mid portion, taking an hourglass-shape 12. The total opening
angle between the lateral and medial wall is 101° to 120° in most asymptomatic shoulders 15.
The bicipital groove plays a critical role, together with the soft tissue sling, in containing the
LHB tendon during its excursions.
Biomechanics of the LHB tendon
The biomechanical function of the LHB tendon has not been completely clarified. Several
cadaver and in vivo biomechanical studies have been performed to assess the role of the LHB
tendon in glenohumeral kinematics. An important function of the LHB tendon is to stabilize
the humeral head within the glenoid during elbow flexion and forearm supination 16. When
the LHB tendon is damaged, the head of the humerus migrates upward on the glenoid. In
addition, the LHB tendon plays a role as a stabilizer of the humeral head on the glenoid
during shoulder abduction in the scapular plane 17.
The LHB tendon contributes to the anterior stability of the shoulder by increasing the
resistance to torsional forces, especially in the abducted and externally rotated position 18.
Moreover, it seems to be able to reduce the stress placed on the inferior glenohumeral
ligament 18. Both the long and short heads of the biceps tendon have a role in the anterior
stabilizer function of the glenohumeral joint 19, helping to resist to anterior humeral head
displacement 19. When anterior shoulder instability occurs, the role of LHB became critical to
maintain the stability. Therefore, strengthening of the biceps is recommended during
rehabilitation in patients with anterior instability of the shoulder 20.
Biceps contraction also limits glenohumeral translation 21. A decreased humeral head
translations anteriorly, superiorly, and inferiorly at the middle and lower elevation angles of
the humerus was found 21. Biceps loading decreases markedly glenohumeral translation
(anterior, posterior, superior and inferior) and rotational range of motion in a simulated
position of 90° of arm abduction and different angles of internal and external rotation 22.
Also, loading of the LHB tendon limits significantly the anterosuperior and superior
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glenohumeral translation in the presence of rotator cuff tears 23.
Morphologic changes of LHB are often combined with rotator cuff tears 24. These findings
support the function of the tendon of the LHB of compensating for abnormal forces produced
in the shoulder when the rotator cuff is damaged. The more common reported anatomical
findings consist of increased size of the LHB. This enlargement leads to increased attrition
during tendon sliding into the bicipital groove and its deterioration.
Biomechanical studies confirmed the role of LHB in stabilizing the glenohumeral joint in all
directions. However, the load applied to the biceps varies widely through the studies.
Moreover, the results of some studies could be biased from non-physiological high loads
applied to the tendon.
Few EMG studies evaluating the effects of the biceps on the shoulder kinematics are
available. Sakurai et al 25 found that the activity of the LHB stabilized the humeral head. On
the other hand, Levy et al 26 found no electrical activity in the LHB tendon with isolated
shoulder motion. They proposed that the stabilizing role of LHB is passive or it is related to
biceps tension associated with elbow or forearm activity. No significant biceps activity was
found during shoulder motion both in patients with normal or torn rotator cuff 27, supporting
the passive function of the biceps tendon in shoulder motion.
Some authors assess the function of the LHB during specific shoulder movements.
Jobe et al 28 analysed throwing and pitching motions in five male subjects by dynamic
electromyography and high speed photography, showing that the biceps predominantly
activates during cocking to accomplish elbow flexion and then reactivates during follow-
through to decelerate the forearm. The muscle patterns observed during the cycle were
largely characteristic of attempts to decelerate the arm 28. The biceps activity was also higher
during windmill pitch than during overhead throw, especially before and after ball release
between 9 o’clock and the follow-through phase 29.
At present, the results of EMG studies do not allow definitive conclusions. Controversies on
the relationship between the activation of the biceps at the elbow and the activity of the
biceps during shoulder movements still needs to be clarified.
Pathologies of the tendon of the LHB
Disorders of the LHB can determine anterior shoulder pain and/or diminished shoulder
function. LHB pathologies include tendinopathy, rupture, SLAP lesions, pulley tears and
tendon instability.
Biceps tendinopathy and tendon rupture
The terminology of LHB tendon pathology has become inconsistent and confusing
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throughout the years. For proper research, assessment and treatment, a uniform and clear
terminology is necessary. The terms “tendinosis”, “paratendinitis”, and “tendinitis” should be
used only after excision biopsy had been examined by a pathologist as these imply specific,
histopathologically proven conditions, with inflammatory cells. The aforementioned terms
should not used in clinical practice.
In inflammatory tendinopathy of the tendon of the LHB, the tendon inflammation can
primary or secondary. Primary tendinitis is the inflammation of the biceps tendon within the
bicipital groove. It is rare, occurring just in 5% of patients with biceps pathology 30.
Therefore, LHB pathology is typically a secondary process, related to others shoulder
problems, such as degenerative rotator cuff lesions, SLAP lesions, impingement syndrome
and acromioclavicular joint disorders 31.
Inflammatory tendinopathy and degenerative tendinopathy usually are related to overuse
consisting of repetitive traction and friction of LHB and glenohumeral rotation, with resultant
pressure and shear forces occurring on the tendon 32. The intra-articular portion of LHB is
surrounded by a sheath originated from synovial lining of the glenohumeral joint.
Inflammation of this sheath can occur in association with inflammatory processes that affect
the rotator cuff tendons 33. The hourglass-shaped LHB tendon is a specific pathological
condition in which the intra-articular portion of tendon is hypertrophic and engages the
superior part of the groove during shoulder motion. The entrapment of LHB within the joint
causes shoulder pain related to tendinopathy and joint locking because of inability of the
tendon to slide into the groove during elevation of the arm 34.
An inflammatory tendinopathy can evolve from LHB tenosynovitis to LHB tendinopathy,
which is marked by specific macroscopic and microscopic features 5, 11, 33. In tenosynovitis,
the biceps tendon appears inflamed and hemorrhagic, but still mobile within the groove.
When the inflammatory process advances, features of early tendinopathy became evident.
The sheath surrounding LHB appears thickened, fibrotic and relatively avascular.
Microscopic findings include: round cell infiltration, mucopolysaccharide deposition and
collagen disorganization 5. The evolution of the degenerative process leads to advanced LHB
tendinopathy, characterized by degenerated tendon, fixed within the groove by scar tissue and
adhesions. A tendinopathic LHB tendon is more likely to rupture spontaneously.
A rupture of the tendon of the LHB is most common in people over 50 years and represents
96% of all biceps brachii injuries 35. Ruptures of the short head or the distal tendon are less
frequent. Traumatic ruptures of the LHB tendon have been reported. However, ruptures are
often spontaneous or associated with little trauma, because they take place in degenerated
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tendon resulting from tenosynovitic and tendinopathic processes 36. The most common sites
of tendon rupture include the tendon origin and the region near the musculotendinous
junction 37. The typical clinical sign of LHB rupture is Popeye deformity, because of the
muscle mass moved distally.
SLAP Lesions
The term “SLAP lesions” was introduced to describe the pathology of superior labrum
extending from anterior to posterior 38. Snyder et al also performed a classification of superior
glenoid and biceps anchor (SLAP) lesions, identifying 4 different types of lesions 38. A type I
SLAP consists of degenerated and frayed superior labrum with the edge still firmly attached
to the glenoid. A type II SLAP consists of the superior labrum and biceps anchor detachment
from the glenoid. A type III SLAP consists of a bucket-handle tear of the superior labrum,
without destabilization of remaining labrum and biceps anchor. A type IV SLAP consists of a
bucket-handle tear of the superior labrum with extension into the biceps tendon. Although
other authors have described further types of SLAP lesions, these are usually a combination
of the above standard types. Type II lesions are the most common, representing 55% of all
lesions, followed by type I lesions (21%), type III lesions (9%), and type IV lesions (10%) 39.
In 5% of the patients, lesions consist in a combinations of type II and III or type II and IV
lesions.
The incidence of SLAP lesions is close to 12% 40. However, data published in literature are
strictly related to experience of shoulder arthroscopists and their ability to recognize such
lesions.
SLAP lesions can be caused by recurrent micro-traumatic impairment, mainly in overhead
athletes, or by single traumatic events. Two different mechanisms of injury have been
proposed to understand the aetiology of superior labral injuries: superior compression and
inferior traction. The superior compression can result from an acute traumatic force occurring
in a fall on the arm with the shoulder positioned in an abducted and slightly forward-flexed
position at the time of impact 39. The superior compression can be also associated with lesions
of rotator cuff leading to a superior migration of the humeral head. Therefore, the superior
labrum and biceps anchor can be damaged and gradually lifted off the glenoid, because of
chronic repetitive superior translation of the humeral head.
74% of individuals with full-thickness rotator cuff tears had also intra-articular lesions,
particularly labral tears 41. Snyder et al 39 detected full- or partial-thickness rotator cuff tears
in 40% of patients with superior labral lesions. Other authors 40, 42, 43 proposed the association
of SLAP lesions with an inferior traction force, occurring with a traumatic, inferior pull on
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the arm, or repetitive micro-trauma, occurring in overhead sport activity with associated
instability.
Biceps instability and pulley tears
LHB instability is usually associated with a rotator cuff tear, especially subscapularis tendon
tears 44-46. The instability varies from subluxation to dislocation and can result in severe
shoulder pain. LHB instability has been reported with a frequency ranging from 6.5% to 20%
and has been observed most commonly in the anterior direction, related to subscapularis tears
46, 47. Although several classification systems for biceps instability have been described 10, 48,
the arthroscopic classification system proposed by Lafosse et al 49 seems to be very useful and
complete. The evaluation of LHB instability has been performed by arthroscopic assessment
with static and dynamic testing of the LHB in maximal external and internal rotation with
various degrees of abduction. This classification system allows to assess direction (anterior,
posterior, or combined anteroposterior) and extent of instability in relation to the bicipital
groove (subluxation or dislocation). Moreover, the macroscopic appearance of the LHB and
the integrity of rotator cuff tendons have been also assessed. The LHB lesions are classified
in grade 0 (no lesion), grade I (minor lesion), and grade II (major lesion). The concomitant
lesions of subscapularis and supraspinatus tendon are classified in three stages: A (intact), B
(partial thickness), and C (full thickness).
Lafosse et al 49 reported instability of the tendon of the LHB in 45% of patients with rotator
cuff tears. The instability direction pattern found was 16% anteriorly, 19% posteriorly and
10% anteroposteriorly. Moreover, the instability of the tendon of the LHB was associated
with LHB lesions in 85% of patients. In instability of the tendon of the LHB, the tendon
presents an increased pathologic anteroposterior movement over the tuberosities. The
“windshield wiper” movement, during internal and external rotation of the arm, produce an
increase of the friction area with subsequent damage of LHB tendon.
Braun et al 50 reported an incidence of pulley lesions of 32.4%. Moreover, they found a
significant correlation between pulley lesions and SLAP lesions, rotator cuff tears and LHB
pathologies 50. Some authors refer pulley lesions to forces on the pulley in external rotation–
abduction positions of the arm 10, 49. Other authors demonstrated that highest shear forces on
the pulley are present in forward flexion and internal rotation of the arm, neutral position of
the arm, neutral position and internal rotation of the arm 9.
Management
The management of LHB pathologies include conservative and surgical modalities.
Conservative management
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Although evidences are lacking, conservative management of symptomatic tendinopathy of
the LHB is commonly undertaken as the first-line treatment. Conservative management is
characterized by the same techniques used for the management of tendon disorders. The first
step consists of rest and nonsteroidal anti-inflammatory drugs. Moreover, physical therapy
can be prescribed to manage concomitant shoulder disorders 3.
When severe inflammation of the sheath of the tendon of the LHB occurs, corticosteroid
injections can be considered 51. Injections are usually performed in the subacromial space and
gleno-humeral joint, managing LHB tendinopathy associated with concomitant shoulder
pathologies. Moreover, injections can be performed within the bicipital groove to spread
corticosteroids in and around the groove without injecting the tendon itself.
Surgical management
The most common indications for surgical treatment of LHB pathologies include 11, 52, 53:
partial-thickness tear of the LHB tendon (>25% to 50%)
medial LHB subluxation
LHB subluxation associated with lesions of the subscapularis tendon or biceps pulley/sling
presence of associated shoulder pathology (rotator cuff and SLAP lesions)
failure of conservative management of LHB tendinopathy.
The best surgical management of LHB tendon pathology has not been identified. The most
common procedures proposed are biceps tenotomy and tenodesis 6.
Biceps tenotomy is usually performed arthroscopicaally. This approach allows surgeon to
assess several aspects of LHB and gleno-humeral pathology. The surgeon should evaluate:
inflammation on surface of both intra-articular and extra-articular portions of tendon 53; shape
and hypertrophy condition of tendon (i.e. hourglass LHB tendon) 34; the stability of the LHB
within the biceps pulley by using a probe and by performing dynamic tests (internal and
external rotation) 49, 54; integrity of rotator cuff tendons (particularly subscapularis and
supraspinatus) and components of the biceps pulley/sling (i.e., CHL, SGHL) 49, 55.
Arthroscopic biceps tenotomy is an effective and reproducible technique providing relief of
shoulder pain arising from LHB pathology. Most patients are able to return to work and
sports 56. Sometimes postoperative pain can remain, because inflamed hypertrophic LHB is
not able to retract into the groove. In these cases, the proximal extremity of tendon should be
debrided 34. Some complications related to biceps tenotomy have been reported. The most
common complications described are Popeye deformity, occurring up to 70% of patients, and
fatigue discomfort in the biceps muscle, occurring in up to 38% of patients 57. Therefore,
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most authors perform tenotomy in older people, not labourers, and people who are unlikely to
be displeased with cosmesis.
Biceps tenodesis is generally performed in younger people, active patients (athletes and
labourers), and people who would avoid cosmetic deformity. The goal of tenodesis is to
preserve the length-tension relationship of the biceps muscle, which may avoid muscle
atrophy and Popeye deformity. Biceps tenodesis can be performed as an arthroscopic or open
procedure. In both instances, the tendon can be fixed within the bicipital groove 58, 59 or out of
this 60-63 (respectively proximal or distal fixation). Distal fixation techniques allow to excise
the intra-articular portion of the tendon by removing it from the bicipital groove. In this way,
it allows to prevent residual postoperative pain from inflammation of the sheath surrounding
the proximal tract of tendon 63. A lower risk of revision surgery has been reported with distal
fixation, outside the biceps groove, than proximal fixation (2.7% versus 12%) 63.
Multiple fixation techniques for LHB tenodesis have been described, including suture anchor
fixation, suture–to–adjacent tissue fixation, keyhole-to-bone fixation, interference screw
fixation, and soft tissue tenodesis 62, 64-71. Although several biomechanical studies comparing
different fixation methods has been described, controversy persists regarding the optimal
fixation technique. Some authors demonstrated superior biomechanical properties of
bioabsorbable interference screws compared with suture anchor 72, 73. Other authors did not
find statistically significant differences in ultimate failure strength among open subpectoral
bone tunnel biceps tenodesis, arthroscopic suture anchor tenodesis, open subpectoral
interference screw fixation, and arthroscopic interference screw fixation 74, 75. However, the
interference screw technique presents the least amount of displacement on cyclic loading
compared with other methods of fixation 76.
Several clinical studies comparing outcomes of tenotomy versus tenodesis have been
published (Tables 1-3). The incidence of Popeye deformity is higher after tenotomy than
tenodesis across all the studies. In a pool data analysis, the incidences were 41% with
tenotomy and 25% with tenodesis 6. Moreover, lower load to tendon failure in tenotomy
compared with tenodesis has been found. Although tenodesis seems to be better than
tenotomy, there is no evidence of significant differences in functional scores or patient
satisfaction between the two techniques. In addition, tenodesis is associated with a higher rate
of bicipital pain (RR 1.4) 77.
Further studies comparing tenotomy and tenodesis are needed. However, both procedures are
effective in the management of LHB tendinopathy.
When symptomatic pulley lesion occur, tenodesis or tenotomy can be performed instead of
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bicipital pulley repair. However, high quality level studies comparing these procedures are
not available.
Biceps tenodesis can be also proposed in patients with superior labral lesions. Boileau
reported higher satisfaction rate and functional outcomes with tenodesis comparing with
repair procedure in patients affected by type II SLAP lesions 78. Moreover, tenodesis or
tenotomy can be combined with rotator cuff repair when LHB pathology is associated with
rotator cuff tears. There is a lower rate of pain after the rotator cuff has been repaired when
the lesion of the tendon of the LHB has been addressed than when the tendon of LHB has
been preserved.
Pathology of the tendon of the LHB and impingement are commonly associated with rotator
cuff tears 4, 20, 71, 77, 79-103. There is significant crossover between rotator cuff tears and long head
of the biceps tendon testing.
Conclusions
The function of the LHB tendon has not been yet completely clarified. Several cadaver and in
vivo biomechanical studies have been performed to assess its role in glenohumeral
kinematics. Biomechanical studies confirmed a role of stabilizer of the glenohumeral joint in
all directions. However, the load applied to the biceps varies widely throughout the studies.
Moreover, the results of some studies could be biased from nonphysiologic high loads
applied to the tendon. Several clinical studies comparing the outcome of tenotomy versus
tenodesis have been published. Although tenodesis seems to be intuitively better than
tenotomy, there is no evidence of significant differences in functional scores or patient
satisfaction between the two techniques. In addition, tenodesis is associated with a higher rate
of bicipital pain. Even though, both procedures are effective for the management of LHB
tendinopathy, further studies comparing these techniques are needed.
Also, further biomechanical research should be focused on assessment of changes in
glenohumeral kinematics when tenotomy or tenodesis of the LHB have been performed.
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619
620
621
622
623
624
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626
627
628
629
630
631
632
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635
636
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638
639
640
641
642
643
644
645
646
20
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119. Pagnani MJ, Deng XH, Warren RF, et al. Role of the long head of the biceps brachii
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1996;5:255-262.
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21
647
648
649
650
651
652
653
654
655
656
657
658
659
660
661
662
663
664
665
666
667
668
669
670
671
672
673
674
21
Table 1
Author Study
Design
(Level of
evidence)
Sample
size (N°
di
patient)
Mean
age, y
(Range
or SD)
FOLLO
W-UP
(months
)
Surgical
Technique
Site of
tenodesis
self-rated
satisfaction
Pain
resolution
Rating
scale
score
pre
score
post
P value Complication
s
Concomitant Surgical
Procedures
Kelly et
al, 2005
104
Case
series /
4
40 48,0 31,0 arthrosopic
tenotomy
68% good,
32% fair
40/40 Insalata;
UCLA;
ASES
75.6;
27.6;
77.6
Not
reported
9 rotator cuff
repair, 5
instability/shrinkag
e, 7 degenerative
joint
disease/debrideme
nt, 8
acromioplasty, 2
manipulation
under anesthesia
for adhesive
capsulitis
Berlema
nn et al,
1995 64
Case-
control
study /3
14 44,6 84 keyhole
tenodesis
proximal
end
into a bal
7/14; Post and
Benca
7%
excellen
t, 67%
good,
14% fair
2 operated
tendons
ruptured;
1
pulmonary
embolisms
Impingement ???
Checchi
a et al,
2005 105
Case-
control
study /3
15 71,0 32,4 arthrosopic
tenodesis
glenoid
cavity
73,3%
excellent;
20 %
good; 6,6
% fair
6/14; UCLA 3,3 1 pz
Popeye
sign
rotator cuff tears in
all pz
Francesc
hi et al,
2007 106
Random
ized
controlle
d
trials / 1
11 58,1 42,7 arthrosopic
tenodesis with
tenotomy
anterior
leaf of
the
rotator
cuff
13/22 UCLA 11,1 32,9 P<0.05 rotator cuff tears in
all pz
11 60,3 arthrosopic
tenodesis
without
tenotomy
UCLA 10,5 33 P<0.05 rotator cuff tears in
all pz
Francesc
hi et al,
2008 107
Random
ized
Controll
ed Trial /
1
32 64,7 62,0 arthrosopic
tenotomy
0 to 4.6 (2-
4)
2.8 (1-4)
to 9.3
(6-10)
UCLA 10,1 32,1 P<0,00
1
8
pz=Popeye
sign
rotator cuff tears in
all pz
Walch et
al, 2005
108
Case-
control
study /3
30 64,3 57,0 Arthroscopic
tenotomy
87% good Constant
score
48.4 67,6 P<0,00
1
Not
reported
rotator cuff tears
Gumina
et al,
2011 109
Case-
control
study /3
30 32,0 31
years
Gilcreest
technique
(open)
suturing
to the
coracoid
tip
100%
good
Constant
score
74 No
complicatio
ns
excluded rotator
cuff tear
Koh et
al, 2010
110
Cohort
study / 2
43 65,0 27,1 Arthroscopic
Tenodesis
Using
a Suture
Anchor
prossimal
e
ASES
score;
Constant
score
84.70;
82.91
? rotator cuff tears,
instability
41 66,0 27,9 ASES
score
Constant
score
79.64;
78.27
? rotator cuff tears
Drakos
et al,
2008 111
Level IV,
therape
utic
case
series
40 38,5 28,0 Arthroscopic
Transfer of
the Long
Head of the
Biceps
Tendon
anterolat
eral
aspect of
the
conjoint
tendon
80% good;
20% fair
38/40 L’Insalata
; UCLA
ASES
75.57;
27.32;
78.72
postoperati
ve ropture
rotator cuff tears,
instability
Scheibel
et al,
2011 112
Cohort
study;
Level of
evidenc
e, 3
30 57,9 19,6 arthroscopic
soft tissue
tenodesis
rotator
interval
12.7 5-
15
Constant
score;
LHB
score
75 - 8 (P>0.05
) -
(P<0.05
)
21 subacromial
impingement, 8
symptomatic
osteoarthrosis of
the
acromioclavicular
joint, 8 Full-
thickness tears
22
675
676
22
27 61,0 22,4 arthroscopic
bony fixation
anchor
tenodesis
Bicipital
groove
13.9 (8-
15)
Constant
score;
LHB
score
78.3 -
11.3
2 SLAP II lesion,
24 rotator cuff
tears, subacromial
impingement, 5
symptomatic
osteoarthrosis
of the
acromioclavicular
joint
Maier et
al, 2011
31
Therape
utic
Level IV
21 51,0 20,2 open
tenodesis
Bicipital
groove
costant
score
26.3 79.3 p<0,01 recurrent
instability
(2PZ);
ROPTURE
(1 PZ)
traumatic
tear of the
subscapularis
tendon
23
677
23
Table 2
First author Technique Position of
tenodesis
Type Sample
size / No
Mean
age, y /
Range
or SD
Load to
tendon
failure / N
Statistically
significance
System machine
Wolf at al, 2005 113 Tenotomy in bicipital
groove
bioabsorbable
interference
screw
6 49 (41-
57)
110.7 P =0 .001 (Materials Testing System;
MTS Systems Corp,
Minneapolis,
MN
Tenodesis 10 310.8
Ahmad at al, 2007
114
Tenotomy -
Healthy Group
7 63.6 21,6 P=0.02 (Bionix 858; MTS, Eden
Prairie, MN)
Tenotomy-
Diseased
Group
7 33.0
Mazzocca at al,
2005 76
Tenodesis proximal
portion of the
bicipital groove
arthroscopic
interference
screw (AIS)
5 78 (18) 237.6 P =0.04 Instron testing
(Model 1321; Instron,
Canton, MA)
Tenodesis proximal
bicipital groove
arthroscopic
suture anchor
(SA)
5 164.8
Tenodesis 1 cm proximal
to where the
inferior border
of the
pectoralis
major tendon
subpectoral
interference
screw (SIS)
5 252.4
Tenodesis inferior border
of the
pectoralis
major tendon
subpectoral
bone tunnel
(SBT)
5 242.4
Richards et al,
2005 115
Tenodesis upper aspect
of the bicipital
groove
arthroscopic
interference
screw
5 52 (44-
57)
233.5 P= 0.007 Servohydraulic materials test
system (MTS) (MTS Model
858; Bionix, MTS Corp,
Minneapolis, MN)
Tenodesis proximal
portion of the
bicipital
arthroscopic
suture anchor
6 135.5
Patzer at al, 2011
116
Tenodesis suprapectoral
position
Bio-SwiveLock
suture anchor
(SSA sup)
7 63 111,2 P>0,05 MTS 858 Mini Bionix
materials testing machine
(MTS GmbH, Berlin,
Germany)
subpectoral
position
Footprint PK
suture anchor
(FSAsub)
7 99,1
suprapectoral
position
Bio-Tenodesis
screw
technique
(BTSsup)
7 218,3
subrapectoral
position
Bio-Tenodesis
screw
technique
(BTSsub)
7 200,7
suprapectoral
position
PEEK Biceptor
tenodesis
screw
(PBCsup)
7 173,9
subapectoral
position
PEEK Biceptor
tenodesis
screw
(PBCsub)
7 162,9
Table 3
Authors Type of study Number of
shoulders
type of test biceps loading Results CONCLUSIONS
Youm et, al 2009
22
cadaveric
study
6 glenohumeral rotational
range of motion,
translation
22 N (linear
bearing)
decrease in external
rotation= 5.0°, internal
rotation= 13.33, in anterior
(2.5 mm) translation
decrease anterioreposterior and
superioreinferior translation
Itoi et al, 1993 117 cadaveric
study
13 translation tests at 9O°
abduction
1,5 Kg (linear
bearing)
anterior displacementc
decreased with arm in 60°
or 90° of external rotation.
stabilised the humeral head for
anterior translation with the arm in
abduction and external rotation.
24
678
679
680
681
24
Kumar et al, 1989
118
cadaveric
study
15 Upward migration
humeral
3 Kg (linear
bearing)
decrease in the
acromiohumeral inter-
Val
long head is necessary to keep the
humeral
head in position during flexion and
supination
of the forearm.
Pagnani et al,
1996 119
cadaveric
study
7 glenohumeral translation
at 50 N forces in
anterior, posterior,
supenor,
and inferior position and
22 N joint compressive
load
50 N (linear
bearing)
translation reduce in all
positions of rotation
the long head of the biceps brachii
contributes to shoulder stability.
Application of a force to the biceps
tendon reduced both anteroposterior
and superoinferior translations
Su et al, 2010 120 cadaveric
study
10 glenohumeral translation
in the intact specimens
and in all sizes of
anterosuperior
and posterosuperior
rotor cuff tear
55 N (linear
bearing)
significant decrease in
both anterosuperior and
superior glenohumeral
translation
25
682
25
... Anterior shoulder pain originating from long head biceps (LHB) tendon pathology can be incapacitating and cause impairment of daily living activities [1]. LHB tendinopathy pain is usually aggravated during overhead movement and forward flexion, limiting the active range of motion [2]. The pathology of LHB includes acute traumatic tears, chronic tendinitis, degenerative changes, and overuse and misuse injuries. ...
Article
Introduction Long head biceps (LHB) tendon pathology results in anterior shoulder pain, affecting activities requiring overhead movement and forward flexion. Current surgical options for those in whom conservative management failed include tenotomy and tenodesis, and both have considerable success rates and various complications. Herein, we present a novel technique using tenotomy with autotenodesis of the LHB. Methods Patients with isolated LHB tendinopathy and for whom the six-month conservative treatment failed were included in our study. Our semitenodesis technique was performed from May 2015 to May 2021. All patients underwent postoperative rehabilitation and were followed in the clinic to document the visual analog scale (VAS) score, constant functional score, supination and flexion power, and postoperative satisfaction score. We used IBM SPSS Statistics for Windows version 20.0 (IBM Corp., Armonk, NY) to analyze our data. Results The study included 26 patients with a mean age of 50 ± 4.3 years and a male predominance. Following our technique, the postoperative VAS score improved significantly from 8.8 to 3 within three months and decreased to 0.4 during the final follow-up. The shoulder average constant score improved significantly from 45 ± 4 to 79 ± 5, in addition to a high postoperative mean satisfaction score. Only one patient had a Popeye sign deformity, making an incidence percentage of 3.8% with our technique. Conclusions We conducted this study to assess the outcomes of our novel technique using tenotomy with autotenodesis of the LHB compared to traditional techniques such as tenotomy and tenodesis. Our novel technique showed an improvement in pain score superior to patients who underwent tenodesis and tenotomy three months postoperatively. Furthermore, our technique yielded lower postoperative complications than traditional techniques. Our patients also scored a high mean of postoperative satisfaction. Therefore, our technique is a promising treatment option, proving its superiority over tenotomy and tenodesis in treating isolated LHB tendonitis.
... 8 Ongoing degeneration may finally end in partial or complete tears of the LHB. 9 Overhead athletes are often affected by pathologies of the LHB. 10 During rotator cuff repair, management of the LHB by tenotomy or tenodesis should be considered to avoid pain and stiffness caused by postoperative biceps tendonitis. 11 Rotator cuff repair may lead to pain and stiffness caused by chronic biceps tendonitis due to an altered anatomy of the rotator interval or irritating sutures in the supraspinatus or subscapularis tendon. ...
Article
Full-text available
The long head of the biceps is an important pain generator of the shoulder joint. Pathologies of the long head of the biceps involve superior labrum anterior to posterior lesions, pulley lesions, partial tears of the biceps tendon, biceps tendonitis, and medial biceps subluxation caused by full-thickness subscapularis tendon tears. Treatment of an inflamed or injured long head of the biceps by either tenotomy or tenodesis is often mandatory during shoulder arthroscopy to avoid persisting pain and possible revision procedures. In comparison with a tenotomy of the biceps tendon, a biceps tenodesis preserves the tension, anatomy, and cosmesis of the biceps muscle. The presented technique demonstrates a single portal technique for a proximal biceps tenodesis in the bicipital groove using an all-suture anchor.
... T he long head biceps tendon (LHBT) originates from the superior glenoid tubercle and superior labrum, passes obliquely through the glenohumeral joint, and bends as it enters the bicipital groove (1). This unique anatomy places it at high risk for inflammatory, traumatic, and degenerative pathologies (2). ...
Article
Full-text available
Background: To describe a case series of young adult patients with isolated chronic proximal biceps tendinitis refractory to conservative care found to have anatomic long head biceps tendon (LHBT) origin variations who underwent arthroscopic-assisted subpectoral biceps tenodesis.
Article
Objectives: We investigated the correlation of aponeurotic expansion of the supraspinatus tendon (AESST) with shoulder pathologies such as long head of biceps tendon (LHB), supraspinatus tendon (SST), and subscapularis tendon (SSc). Methods: We retrospectively evaluated 47 healthy patients and 163 patients with shoulder symptoms from January 2019 to February 2019. First, the presence of AESST was evaluated based on Moser et al.'s classification. Second, the presence of abnormal findings of including LHB tendinitis, LHB subluxation, SST tendinitis, SST tear, SSc tendinitis, and SSc tendon tear was evaluated. We analyzed the prevalence and type of AESST between the two study groups and the relationship between abnormal findings and the presence of AESST. Results: The prevalence of AESST for readers 1 and 2 was 26.1% and 30.4% in the asymptomatic group, respectively, and 22.8% and 31.3% in the symptomatic group. Type 1 was most common (17.3-23.9%) followed by types 2a and 2b. There were no significant differences in the distribution of aponeurosis type between the two groups. In the AESST-positive groups, 45.9% and 47.1% had SST tears on examination by readers 1 and 2, respectively, whereas only 26.4% and 27.9% had SST tears in the AESST-negative group suggesting AESST is associated with SST tear. The odds ratio for SST tear in the presence of AESST was 2.370 and 2.294 (readers 1 and 2). Conclusions: There is an association between SST tears and the presence of AESST. Key points: • We evaluated the prevalence of aponeurotic expansion of the supraspinatus tendon (AESST) on MR imaging by type in both symptomatic and asymptomatic groups. • We investigated the correlation of AESST with shoulder pathologies such as biceps tendon and supraspinatus tendon tears. • There is an association between SST tears and the presence of AESST. • Radiologists should be aware of the risk of rotator cuff pathology if AESST is detected.
Preprint
Full-text available
Background: A comparison of changes in the long head of the biceps tendon for different types of rotator cuff tears has not been previously performed. Furthermore, the correlation between the thickening and degeneration of the long head of the biceps tendon and the cause of these changes have not been fully clarified. We evaluated the relationship between degenerative changes in the long head of the biceps tendon and rotator cuff tears in a rat model using imaging and histology. Methods: Ninety-six 12-week-old Sprague-Dawley rats were divided into anterior (subscapularis tear), anterosuperior (subscapularis, supraspinatus, and infraspinatus tears), superior (supraspinatus and infraspinatus tears), and control groups. The long head of the biceps tendon was harvested at 4 or 12 weeks postoperatively. The cross-sectional areas of the intra- and extra-capsular components of the tendon were measured using micro-computed tomography, and the affected/normal ratio of the cross-sectional area was calculated. Masson’s trichrome staining and Alcian blue staining were performed for histologic analysis, with degenerative changes described using the modified Bonar scale. The correlation between the affected/normal ratio and Bonar scores was evaluated. Results: The affected/normal ratio was higher for the anterior and anterosuperior groups than for the control group at 4 and 12 weeks. The ratio increased for the intra-articular portion in the superior group and for both the intra- and extra-articular portions in the anterior and anterosuperior groups. Degeneration considerably progressed in the anterior and anterosuperior groups compared with the control group from weeks 4 to 12 and was greater in the intra- than in the extra-articular portion. The ratio correlated with extracellular matrix score. Conclusions: Subscapularis tears were associated with progressive thickening and degeneration of the long head of the biceps tendon at 4 and 12 weeks postoperatively, which was more significant in the intra- than in the extra-articular portion. Histologic evaluation indicated that the extracellular matrix likely caused these degenerative changes.
Article
Background: The purpose of this study was to compare the initial fixation strength between four different suture methods for the long head of the biceps. Methods: Forty-eight fresh frozen porcine flexor hallucis longus tendons (mean width at suture site, 8.5 ± 0.9 mm) and phalanx bones were randomly assigned to one of the four arthroscopic biceps tenodesis techniques: simple stitch (SS), mattress suture (MS), lasso-loop (LL), and two simple stitches (2SS). A biceps tenodesis was performed according to the four techniques using all-suture type suture anchors (1.9-mm SUTUREFIX anchor with No. 1 ULTRABRAID sutures). Biomechanical evaluations were performed to test load to failure (N), stiffness (N/mm), stress (N/m2), and mode of failure. Results: As for the SS, MS, LL, and 2SS, the mean load to failure was 50.9 ± 14.61 N, 82.3 ± 24.8 N, 116.2 ± 26.7 N, and 130.8 ± 22.5 N (p < 0.001), respectively; mean stiffness was 6.1 ± 1.3 N/mm, 6.7 ± 2.6 N/mm, 7.8 ± 1.4 N/mm, and 8.1 ± 4.2 N/mm, respectively (p = 0.258); and mean stress was 0.7 ± 0.3 N/m2, 1.4 ± 0.8 N/m2, 2.9 ± 0.7 N/m2, and 2.7 ± 0.8 N/m2, respectively (p < 0.001). All the failures happened by the suture cutting through the tendon along its longitudinal fibers. Conclusions: Neither the SS nor the MS method was enough to securely fix the biceps tendon with a significantly lower mechanical strength; however, the 2SS method showed similar initial fixation strength as the LL technique.
Article
Résumé Introduction Les douleurs d’épaule liées à une tendinopathie de la longue portion du biceps (LPB) sont fréquentes. Le traitement chirurgical par ténotomie arthroscopique de la LPB a montré son efficacité. Cependant cette efficacité n’est pas constante. L’objectif était d’évaluer les facteurs pronostiques cliniques et radiologiques préopératoires d’une chirurgie arthroscopique de ténotomie du long biceps, et d’établir un score prédictif de bonne réponse au traitement : le score IBTIS (Isolated Biceps Tenotomy Index Score). Hypothèse Il existe des facteurs de pronostic de bonne réponse au traitement de tendinopathie de LPB par ténotomie arthroscopique. Matériel et méthodes Nous avons réalisé une étude monocentrique rétrospective incluant 64 patients opérés entre janvier 2018 et mars 2020 d’une chirurgie arthroscopique de ténotomie de la LPB, associée ou non à une ténodèse. Nous avons identifié 2 groupes de patients à partir d’une évaluation clinique à 3 mois postopératoire, qui comprenait une évaluation subjective par le score Single Shoulder Value (SSV), le score de Constant, le C-Test, et la douleur : un groupe bon répondeur et un groupe mauvais répondeur. Des facteurs pronostiques de bonne réponse étaient alors recherchés entre les 2 groupes à partir de l’interrogatoire, de l’examen clinique et de l’imagerie préopératoire. À partir de ces facteurs, un score prédictif de bonne réponse a été établi. Résultats Tous les critères d’évaluation retrouvaient une amélioration postopératoire : SSV moyen (72,2 Vs 50,7 ; p < 0,001), Constant pondéré (78,2 Vs 64,3 ; p < 0,001), douleur (3,2 Vs 7 ; p < 0,001), C-Test (94,1 Vs 85,6 ; p = 0,07). 34 patients (58,6 %) étaient considérés comme bons répondeurs, 24 patients (41,38 %) comme mauvais répondeurs. On retrouvait une tendance à un résultat favorable concernant : âge > 65 ans (p = 0,01), rupture de coiffe sur imagerie préopératoire (p = 0,01), le Cross Arm Test (p = 0,02), douleur nocturne (p = 0,08), Yergason test (p = 0,16), Speed Test (p = 0,22). La réalisation d’un travail manuel semblait être un facteur d’évolution défavorable (p = 0,07). Ces facteurs ont été intégrés dans le score IBTIS sur 10 points. Un score supérieur à 5 était associé à un résultat favorable chez plus de 80 % des patients (p < 0,001). Discussion Notre score regroupe 7 items. Nous avons identifié 7 facteurs pronostiques préopératoires de bons résultats après ténotomie de la LPB. L’âge supérieur à 65 ans était retrouvé statistiquement significatif dans l’analyse univariée de même que la visualisation d’une rupture de la coiffe des rotateurs sur l’imagerie préopératoire. Le Cross Arm Test a été inclus compte tenu d’une forte significativité statistique. Le Speed Test et le Yergason Test sont omniprésents dans la littérature. Les douleurs nocturnes étaient retrouvées chez plus de 80 % des patients. La réalisation d’un travail manuel représentait un facteur pronostique péjoratif après réalisation d’un geste arthroscopique sur la LPB. Conclusion Le score IBTIS (Isolated Biceps Tenotomy Index Score) est un score clinico-radiologique préopératoire en vue d’un traitement chirurgical de ténotomie arthroscopique du long biceps. Des études complémentaires devront être effectuées pour valider sa précision pronostique. Niveau de preuve III ; étude cas-témoin.
Chapter
A tendon is a closely compact band of connective tissue-fibers well organized in length and strength which connects to muscle and transmits the required force developed by the muscle. The musculoskeletal is such that bones are driven by tendons and produce joint motion in coordination with muscles activities. Each muscle connects to tendon which in turn is solidly attached to bone. Tendons are characterized by high resistance to mechanical loads, greater tensile strength and fibrous-elastic properties, thanks to which they can transmit the muscular forces directly to the bone with minimum energy dissipation. Accurate knowledge of their molecular and biochemical composition is essential to better understand the function of these important anatomical structures.
Article
Introduction: Shoulder pain associated with tendinopathy of the long head of biceps (LHB) is common. Surgical treatment with arthroscopic tenotomy of the LHB has been shown to be effective. However, it’s efficacy is inconsistent. The objective of this study was to assess the pre-operative clinical and radiological prognostic factors of arthroscopic tenotomy of the long head of biceps, and to establish a predictive score for good responses to treatment; the IBTIS score (Isolated Biceps Tenotomy Index Score). Hypothesis: Prognostic factors representing a good response to treatment of LHB tendinopathy by arthroscopic tenotomy exist. Materials and methods: We conducted a retrospective monocentric study including 64 patients who underwent surgery of the LHB by arthroscopic tenotomy (with or without tenodesis) between January 2018 and March 2020. We identified 2 patient groups (good responder group and poor responder group) from a 3-month post-operative clinical assessment, which included a subjective assessment comprising Single Shoulder Value (SSV), Constant score, C-Test, and pain level. Prognostic factors of a good response were then sought from the 2 groups using interviews, clinical examinations and pre-operative imaging. Based on these findings, a predictive score for a good response was established Results: All evaluation criteria demonstrated post-operative improvement: mean SSV (72.2 vs 50.7; p<0.001), relative constant (78.2 vs 64.3; p<0.001), pain level (3.2 vs 7; p<0.001) and C-Test (94.1 vs 85.6; p=0.07). 34 patients (58.6%) were considered good responders, while 24 patients (41.38%) were considered poor responders. There was a trend towards a favourable result for: age>65 years (p=0.01), rotator cuff rupture on preoperative imaging (p=0.01), Cross Arm Test (p=0.02), nocturnal pain (p=0.08), Yergason’s test (p=0.16) and Speed’s Test (p=0.22). Manual labour appeared to be an unfavourable factor (p=0.07). These factors were incorporated into the 10-point IBTIS score. A score greater than 5 was associated with a favourable result in more than 80% of patients (p<0.001). Discussion: Our score consists of 7 items. We identified 7 pre-operative prognostic factors for a good result after LHB tenotomy. Over 65 years of age was found to be statistically significant in univariate analysis, as was visualization of rotator cuff rupture on pre-operative imaging. The Cross Arm Test was included given its high statistical significance. The Speed’s Test and Yergason’s Test are ubiquitous in the literature. Nocturnal pain was found in more than 80% of patients. Undertaking manual labour represented an unfavourable prognostic factor after arthroscopic surgery of the LHB. Conclusion: The IBTIS score (Isolated Biceps Tenotomy Index Score) is a pre-operative clinico-radiological score for the surgical treatment of arthroscopic tenotomy of the long head of biceps. Further studies are required to validate its prognostic accuracy. Level of evidence: III; case-control.
Article
Biceps tenodesis and tenotomy are increasingly being used as treatment options for shoulder pathology, but patient satisfaction remains largely unstudied. A systematic review of the MEDLINE database was conducted to identify clinical outcome studies on isolated biceps tenodesis or tenotomy that reported patient satisfaction. Within the 15 investigations that were included, the indication for tenotomy was rotator cuff pathology, whereas the indication for tenodesis was biceps pathology or type 2 superior labral tear from anterior to posterior. Patients undergoing tenotomy were 13.6 years older than those undergoing tenodesis (P<.001). Patient satisfaction was high following both procedures, at 85.6% following tenotomy and 92.3% following tenodesis. [Orthopedics. 202x;xx(x):xx-xx.].
Article
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Most arthroscopic rotator cuff reconstruction techniques require a method of securing the tendon to the bone to obtain a stable construct. The available options include knotless technology and suture welding, but the most common method uses suture anchors and knots. Tissue quality, surgical technique, repair material, and tension overload influence the stability of tissue repair. Arthroscopic knots are technically demanding because they are tied through cannulas with long-handled knot pushers. The strength of the repair is also influenced by the suture material used. In this study, we review the state-of-the-art of arthroscopic knots and suture materials being used for arthroscopic rotator cuff repair.
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The open tendon suture is the most commonly used method of treatment for Achilles tendon rupture in Germany. Over the last decade the therapeutic spectrum of operative methods has been further enlarged by the development of new minimally invasive surgical techniques. Important criteria for planning treatment are the location and age of the rupture and comorbidities. For recent Achilles tendon ruptures minimally invasive suturing is indicated but for older ruptures a reconstruction often has to be carried out. The decisive disadvantage of an open tendon suture is the relatively high risk of infection. Using minimally invasive surgical techniques the frequency of postoperative infection could be significantly reduced. The suture methods without opening the ruptured region can be collectively grouped under the term percutaneous suture techniques and the minimally invasive methods with opening of the rupture region as combined open percutaneous techniques. Documented problems with the Ma-Griffith technique, such as injury of the sural nerve, low stability of the suture and insufficient adaption of the tendon stumps have been minimized by new minimally invasive operation techniques. Achilles tendon ruptures which nearly always arise without any external influence or accidents can have substantial psychological consequences regarding the integrity of one’s own body especially for people actively engaged in sport. This aspect should be considered and accepted in particular during postoperative treatment.
Article
Full-text available
Background: Vertebral compression fractures (VCFs) constitute a major health care problem in western countries. Several treatments modalities are available to relieve pain and allow increased activities. Percutaneous vertebroplasty (the injection of bone cement into the fractured vertebral body) is a relatively new procedure to manage patients with these fractures. The aim of this study is to evaluate the efficacy and safety of percutaneous vertebroplasty compared with standard conservative care. Methods/designs: In this double blind, prospective, randomized, controlled study the short- (3 months), medium- (6 months) and long-term (24 months) efficacy and safety of vertebroplasty to alleviate pain and improve function for painful osteoporotic vertebral fractures will be compared to standard conservative therapy. Conservative care will consist of 3 weeks of bed rest, wearing a rigid hyperextension corset, followed by 2-3 months in a Cheneau brace. In each of the two groups, patients will also receive treatment for osteoporosis according to their metabolic profile. Two hundred patients with painful osteoporotic vertebral compression fractures will be recruited over a 3 year period according to inclusion and exclusion criteria. We will randomly assign participants to receive either vertebroplasty or conservative care. Subjects will complete a battery of validated, standardized measures of pain, functional disability, and health related quality of life questionnaires at baseline and at post-randomization time points (1, 3, 6, 12 and 24 months). Each patient will be evaluated for pre-operative MRI, and pre- and post-operative radiographs; all scans will be evaluated independently by 2 orthopaedic surgeons. Laboratory tests to assess their metabolic bone profile will be also performed. Our primary outcome will be change from baseline to 1, 3, 6, 12 and 24 months in the VAS score between the 2 groups. Discussion: To date, vertebroplasty has been not been compared with standard conservative care for the management of patients with painful osteoporotic vertebral fractures in a randomised controlled trial. Therefore, the results of this study will allow to draw firm conclusions on this controversial topic.
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The subscapularis muscle is the largest and strongest muscle of the rotator cuff. It plays an essential role in the stability and function of the shoulder. Tears of the subscapularis tendon are more frequent than previously estimated. The worldwide use of arthroscopy in rotator cuff surgery has allowed to recognize the true prevalence of subscapularis lesions, as it permits to visualize the articular side where partial tears are usually localized. Subscapularis tears are generally non-traumatic, arising from intrinsic degeneration, subcoracoid and/or anterosuperior impingement. Clinical presentation is usually characterized by history of pain, typically located anteriorly, and difficulty in lifting movements across the chest, or twisting inwards that hinders activities of daily life. Special tests for the diagnosis of subscapularis tears include the lift-off, belly-press, and bear-hug tests. Imaging of the subscapularis tendon may involve plain radiography, magnetic resonance and ultrasound scanning, but MRI better characterizes subscapular tears and coexistent shoulder pathology. The management of subscapularis tears is aimed at restoring the integral role of this muscle in the shoulder. Operative management is indicated for most patients because it is the only one to allow restoration of subscapularis function. Arthroscopic repair can be safely and successfully performed. It requires tendon mobilization to reach the lesser tuberosity. If this is not possible, its footprint can be medialized up to 5-7 mm. Arthroscopic results are encouraging. At intermediate follow-up, improvement in functional scores and patient satisfaction has been reported. Outcomes are comparable to that of open repair, with a very low complication rate and no major intraoperative complications.
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Background Treatment of chronic, refractory biceps tendinitis remains controversial. The authors sought to evaluate clinical and functional outcomes of arthroscopic release of the long head of the biceps tendon. Hypothesis In specific cases of refractory biceps tendinitis, site-specific release of the long head of the biceps tendon may yield relief of pain and symptoms. Study Design Case series; Level of evidence, 4. Methods Fifty-four patients diagnosed with biceps tendinitis underwent arthroscopic release of the long head of the biceps tendon as an isolated procedure or as part of a concomitant shoulder procedure over a 2-year period. Patients were not excluded for concomitant shoulder abnormality, including degenerative joint disease, rotator cuff tears, Bankart lesions, or instability. Nine of 40 patients had an isolated arthroscopic release of the biceps tendon. At a minimum of 2 years, the American Shoulder and Elbow Surgeons; the University of California, Los Angeles; and the L'Insalata shoulder questionnaires as well as ipsilateral and contralateral metrics were used for evaluation. Results The L'Insalata; University of California, Los Angeles; and American Shoulder and Elbow Surgeons scores were 77.6, 27.6, and 75.6, respectively. Seventy percent had a Popeye sign at rest or during active elbow flexion; 82.7% of men and 36.5% of women had a positive Popeye sign (P <. 05); 68% were rated as good, very good, or excellent. No patient reported arm pain at rest distally or proximally; 38% of patients complained of fatigue discomfort (soreness) isolated to the biceps muscle after resisted elbow flexion. Conclusion Arthroscopic release of the long head of the biceps tendon is an appropriate and reliable intervention for patients with chronic, refractory biceps tendinitis. Cosmetic deformity presenting as a positive Popeye sign and fatigue discomfort were the primary complaints. Clinical Relevance Although tenotomy is not the ideal intervention for patients of all ages with various shoulder abnormalities, data suggest that it may be an acceptable surgical intervention for a specifically selected cohort of individuals.
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Traditional management of end-stage pain and degeneration of the proximal biceps tendon has included open tenodesis of the biceps tendon. Several methods have been described. More recently, however, arthroscopic techniques have been developed. This article introduces a novel method of arthroscopic biceps tenodesis that does not require any specialized hardware.
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Objective Resection of the intraarticular part of the long head of the biceps and tenodesis to decrease shoulder pain due to a pathologically altered biceps tendon and to improve shoulder function. Indications Tenosynovitis. State of prerupture. Instability (subluxation or dislocation of tendon from intertubercular groove). Intraarticular entrapment secondary to hypertrophy of the long head of the biceps in the presence of an intact cuff. To be performed during arthroscopic cuff repair or during debridement of an irreparable cuff tear. Contraindications Very thin, frayed, almost ruptured biceps tendon. Complete rupture of the long head of the biceps. Surgical Technique Standard arthroscopy with 30° scope inserted through the posterior portal. Detachment of the long head from the glenoid origin. Longitudinal opening of the bicipital groove. Exteriorization and doubling of the tendon. Drilling of a socket starting in the groove but perforating the posterior cortex only with a guide wire. Passing of the tendon in an anteroposterior direction and securing the anchorage with a bioresorbable PLA interference screw. Results Between 1997 and 1999, an arthroscopic tenodesis was performed in 43 patients. Minimum follow-up 2 years. The absolute Constant Score improved from 43 points preoperatively to 79 points at the time of follow-up. No loss of elbow extension or flexion; power of biceps after tenodesis 90% of opposite side. Early on, two failures of tenodesis occurred.
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Since the 17th century, the long head of the biceps tendon as a source of shoulder pain and its functional significance has been a source of debate. Although the term tendinitis is commonly used, overuse tendon injuries infrequently demonstrate inflammatory cells; instead, degenerative changes resulting from the failure of self-repair usually are found. Bicipital tendinitis or bicipital tenosynovitis is most often secondary to impingement beneath the coracoacromical arch. Primary bicipital tendinitis and tendinitis secondary to instability are possible, however. Through a careful history, physical examination, and appropriate imaging studies, the clinician can establish the diagnosis of disorders of the biceps tendon Arthroscopic evaluation greatly improves the diagnosis and treatment of biceps tendon and related shoulder pathology. Although the exact functional role of the biceps tendon remains incompletely defined, a growing body of evidence supports its role as a stabilizer of the glenohumeral joint. This stabilizing function should be incorporated into the treatment of biceps tendon disorders. Routine tenodesis has been replaced by a more individualized approach, taking into consideration physiologic age, activity level, expectations, and exact shoulder pathology present. New repair techniques are under development, and preservation of the biceps-labral complex is now preferred when possible.