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Pianka MA, Sundaram V, Wolfe I, Lezak B, Moore MR, Alaia MJ, Feldman AJ, Jazrawi LM. Long-term patient-reported outcomes of open subpectoral biceps tenodesis with cortical button fixation. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024:10.1007/s00590-024-04036-z. [PMID: 39060553 DOI: 10.1007/s00590-024-04036-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Accepted: 06/24/2024] [Indexed: 07/28/2024]
Abstract
BACKGROUND Open subpectoral biceps tenodesis (OSBT) with cortical button fixation has been shown to deliver acceptable results in the short and intermediate term for long head of the biceps (LHB) pathology with the benefit of smaller bone tunnel diameter and a reduced risk of postoperative humeral shaft fracture. The primary purpose of this study was to determine whether OSBT with cortical button fixation results in significant improvements in patient reported outcomes (PROs) from pre-operative to long-term final follow-up. METHODS A retrospective analysis of patients who underwent OSBT with cortical button fixation at a single institution between the years of 2012 and 2014 was conducted and PROs were collected in the intermediate (> 2 years follow-up) and long term (> 9 years follow-up). PROs were measured pre-operatively, at intermediate follow-up, and at long-term follow-up using three validated questionnaires: American Shoulder and Elbow Surgeons (ASES) score, Disabilities of the Arm, Shoulder, and Hand (DASH) score, and Oxford Shoulder Score (OSS). Patients were additionally asked at final follow-up if they would undergo the same procedure again if they needed it. RESULTS Twenty-nine (29) patients with a mean age of 51.16 ± 9.06 years at the time of surgery were included in the study at final follow-up. Mean final follow-up time was 10.2 ± 0.5 years (range: 9.2-11.1 years). All PROs (ASES, OSS, and DASH) demonstrated statistically significant improvements from pre-operative to final follow-up with p < 0.01 for each. The proportions of patients exceeding established values for minimum clinically important difference (MCID) were 96.55%, 93.10%, and 75.86% for ASES, OSS, and DASH respectively. Only one patient had required re-operation as of final follow-up. None experienced humeral fractures post-operatively. A significant majority (89.66%; p < 0.01) of patients reported that they would undergo the same procedure again if they needed it. Fifty-three (53) patients were included in the study at intermediate follow-up with a mean follow-up time of 3.5 ± 1.4 years (range: 2-5.3 years). There were no statistically significant differences in any of the PRO measures from intermediate to long-term follow-up. CONCLUSION This study reported a minimum 9-year follow-up of patients undergoing OSBT with cortical button fixation for the management of LHBT pathology in the setting of concomitant shoulder procedures. All patients had significantly improved functional outcomes assessed with ASES, OSS, and DASH and no obvious differences in median group scores were found between patients assessed at intermediate (mean 3.5 years) and final (mean 10.2 years) follow-up. No infections, fractures, or fixation failures were reported.
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Affiliation(s)
- Mark A Pianka
- Department of Orthopedic Surgery, NYU Langone Health, 333 East 38th St, New York, NY, 10016, USA
| | - Vishal Sundaram
- Department of Orthopedic Surgery, NYU Langone Health, 333 East 38th St, New York, NY, 10016, USA.
| | - Isabel Wolfe
- Department of Orthopedic Surgery, NYU Langone Health, 333 East 38th St, New York, NY, 10016, USA
| | - Bradley Lezak
- Department of Orthopedic Surgery, NYU Langone Health, 333 East 38th St, New York, NY, 10016, USA
| | - Michael R Moore
- Department of Orthopedic Surgery, NYU Langone Health, 333 East 38th St, New York, NY, 10016, USA
| | - Michael J Alaia
- Department of Orthopedic Surgery, NYU Langone Health, 333 East 38th St, New York, NY, 10016, USA
| | - Andrew J Feldman
- Department of Orthopedic Surgery, NYU Langone Health, 333 East 38th St, New York, NY, 10016, USA
| | - Laith M Jazrawi
- Department of Orthopedic Surgery, NYU Langone Health, 333 East 38th St, New York, NY, 10016, USA
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Siang Koh DT, Puah KL, Meng Goh JK, Tan YH, Sheng Tan ET, Tjoen Lie DT. Raised Body Mass Index and Reduced Muscle Bulk Reduces The Incidence Of Popeye's Deformity Post Tenotomy Of Long Head of Biceps Brachii. J ISAKOS 2024:S2059-7754(24)00129-9. [PMID: 39019402 DOI: 10.1016/j.jisako.2024.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Revised: 06/23/2024] [Accepted: 07/11/2024] [Indexed: 07/19/2024]
Abstract
OBJECTIVES The development of the Popeye's deformity is a known complication of long head of bicep tendon (LHBT) tenotomy. Incidence of developing Popeye's deformity after LHBT tenotomy ranges between 13 - 70%. While this complication is well tolerated, it can be avoided with proper patient selection. We aim to study patient and clinical factors resulting in the development of the Popeye's deformity after LHBT tenotomy so as to better identify suitable surgical candidates. METHODS 91 patients underwent unilateral rotator cuff repairs and concomitant LHBT tenotomy between March 2013 and March 2017. Assessment of patient factors contributing to Popeye's deformity included patient demographics and physical attributes were analysed and correlated. Patients also completed a questionnaire regarding their overall post-operative satisfaction. Prospectively collated Visual Analogue Pain (VAS), Constant-Murley Shoulder Score (CSS), UCLA Shoulder Score (UCLA) and Oxford Shoulder Score (OSS) were compared at 6 and 24 months post-operation between patients who developed Popeye's deformity and those who did not. RESULTS The incidence of post-tenotomy Popeye's sign was 58.9%. Majority of patients were satisfied with their procedure, postoperative function and cosmesis. Patients who developed Popeye's sign had a statistically significant lower body mass index (BMI) (24.9 ± 4.2 kg/m2 versus 27.3 ± 4.3 kg/m2, p = 0.048) (rpb = - 0.210, p > 0.05) and had a greater biceps circumference (in flexion) to wrist circumference ratio (1.91 ± 0.16 versus 1.83 ± 0.13, p = 0.012) (rpb = 0.319, p < 0.05) compared to those who did not. Nevertheless, the development of Popeye's sign did not affect clinical outcomes (VAS, CSS, UCLA and OSS, p > 0.05) at 24 months. CONCLUSIONS The incidence of Popeye's deformity is high post LHBT tenotomy. There was a greater incidence in patients with lower BMI and greater biceps brachii muscle bulk. However, this complication is well tolerated. By better selecting our patients, we can achieve better outcomes and minimise potential complications. LEVEL OF EVIDENCE Level III Evidence. Retrospective comparative study.
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Affiliation(s)
- Don Thong Siang Koh
- Department of Orthopaedic Surgery, Singapore General Hospital, 20 College Road, Academia Building Level 4, Singapore 169856
| | - Ken Lee Puah
- Artisan Sports & Orthopaedic Clinic, Paragon Medical Centre
| | - Jeremy Keng Meng Goh
- Department of Orthopaedic Surgery, Singapore General Hospital, 20 College Road, Academia Building Level 4, Singapore 169856
| | - Yong Hong Tan
- Department of Orthopaedic Surgery, Singapore General Hospital, 20 College Road, Academia Building Level 4, Singapore 169856
| | | | - Denny Tijauw Tjoen Lie
- Department of Orthopaedic Surgery, Singapore General Hospital, 20 College Road, Academia Building Level 4, Singapore 169856
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Light JJ, du Plessis W, Adsit MH, Eckstrom AT, Firoved AB, Griffin JW, Bonner KF. Mild Biceps Tendonitis May Be Managed Nonoperatively During Shoulder Arthroscopy. Arthrosc Sports Med Rehabil 2023; 5:100785. [PMID: 37753186 PMCID: PMC10518440 DOI: 10.1016/j.asmr.2023.100785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 07/09/2023] [Accepted: 07/17/2023] [Indexed: 09/28/2023] Open
Abstract
Purpose The purposes of this study were to determine whether patients with mild biceps tendonitis required revision surgery after the biceps tendon was not surgically treated, while addressing concomitant pathology, and to evaluate whether preoperative groove pain affected patient-reported outcomes. Methods Patients who underwent shoulder arthroscopy between 2015 and 2018 by a single surgeon for rotator cuff pathology, debridement, and distal clavicular excision (DCE), with or without subacromial decompression (SAD), and where the biceps tendon was not surgically addressed were retrospectively identified. Inclusion criteria were mild LS (<50% hyperemic appearing biceps tendon arthroscopically), and a minimum 2-year follow-up. The primary outcome measure was the incidence of revision surgery. Secondary outcomes included American Shoulder and Elbow Surgeons (ASES) score, simple shoulder test (SST), pain level, and satisfaction scores. Two sample t-tests compared postoperative patient-reported outcomes based on the presence or absence of preoperative bicipital groove tenderness. Results Sixty-four of 69 eligible subjects (93%) were evaluated at a minimum of 2 years postoperatively. One out of 64 subjects underwent revision to perform a biceps tenodesis. Overall, patients had high patient-reported outcome measures (PROMs) postoperatively. Ninety-seven percent of patients reported they would have the surgery again. The presence of preoperative bicipital groove tenderness had no effect on ASES (P = .62), SST (P = .83) scores, and postoperative pain (P = .65). Patients without bicipital groove pain had average respective ASES and SST scores of 93.70 ± 11.84 and 10.66 ± 2.47; those with bicipital groove pain averaged 92.00 ± 15.31 and 10.78 ± 1.87. There was no significant difference in overall satisfaction scores between patients with groove pain (9.42 ± 1.40) and those without (9.46 ± 1.38; P = .92). Conclusions Patients with mild biceps tendonitis showed favorable outcomes with low revision rates and high patient satisfaction when the biceps tendon was not surgically addressed when the primary shoulder pathology was treated during arthroscopy, independent of preoperative groove pain. Level of Evidence Level III, retrospective cohort study.
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Affiliation(s)
| | - Wihan du Plessis
- Eastern Virginia Medical School, Norfolk, Virginia, U.S.A
- Ohio Health-Riverside Methodist Hospital, Columbus, Ohio, U.S.A
| | - Matthew H. Adsit
- Eastern Virginia Medical School, Norfolk, Virginia, U.S.A
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, Virginia, U.S.A
| | | | - Amanda B. Firoved
- Jordan-Young Institute for Orthopedic Surgery & Sports Medicine, Virginia Beach, Virginia, U.S.A
| | - Justin W. Griffin
- Eastern Virginia Medical School, Norfolk, Virginia, U.S.A
- Jordan-Young Institute for Orthopedic Surgery & Sports Medicine, Virginia Beach, Virginia, U.S.A
| | - Kevin F. Bonner
- Eastern Virginia Medical School, Norfolk, Virginia, U.S.A
- Jordan-Young Institute for Orthopedic Surgery & Sports Medicine, Virginia Beach, Virginia, U.S.A
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Sohn HJ, Cho CH, Kim DH. Bilateral dislocation of the long head of biceps tendon with intact rotator cuff tendon: A case report. World J Clin Cases 2023; 11:6304-6310. [PMID: 37731569 PMCID: PMC10507544 DOI: 10.12998/wjcc.v11.i26.6304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 08/16/2023] [Accepted: 08/21/2023] [Indexed: 09/08/2023] Open
Abstract
BACKGROUND Dislocation of the long head of biceps tendon (LHBT) usually involves rotator cuff injury, and isolated dislocation with an intact rotator cuff is rare. Some cases of isolated dislocation have been reported. However, to the best of our knowledge, there has been no report of bilateral dislocation of the LHBT without rotator cuff pathology. CASE SUMMARY A 23-year-old male presented to our outpatient clinic with left side dominant pain in both shoulders. The patient had no history of trauma or overuse. The patient underwent intra-articular injection and physical therapy, but his symptoms aggravated. Based on preoperative imaging, the diagnosis was bilateral dislocation of the LHBT. Dysplasia of the bicipital groove was detected in both shoulders. Active dislocation of the biceps tendon over an intact subscapularis tendon was identified by diagnostic arthroscopy. Staged biceps tenodesis was performed and continuous passive motion therapy was administered immediately after surgery. The patient's pain was resolved, and full functional recovery was achieved, and he was satisfied with the condition of his shoulders. CONCLUSION This study describes a rare case of bilateral dislocations of the LHBT without rotator cuff injury due to dysplasia of the bicipital groove.
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Affiliation(s)
- Hyuk-Joon Sohn
- Department of Orthopedic Surgery, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu 42601, South Korea
| | - Chul-Hyun Cho
- Department of Orthopedic Surgery, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu 42601, South Korea
| | - Du-Han Kim
- Department of Orthopedic Surgery, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu 42601, South Korea
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Aydin M, Capkin S, Surucu S, Karahasanoglu R, Yilmaz M. The effect of biceps tenotomy on superior humeral migration in arthroscopic repaired full-thickness supraspinatus tears. JSES Int 2023; 7:768-773. [PMID: 37719819 PMCID: PMC10499908 DOI: 10.1016/j.jseint.2023.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023] Open
Abstract
Background Lesions of the long head of the biceps (LHB) tendon are a prevalent injury that frequently coexists with rotator cuff injuries. This study aimed to assess the effect of supraspinatus (SST) repair with concurrent LHB tenotomy on superior migration of the humeral head. The acromiohumeral distance (AHD) was determined via ultrasound to evaluate the superior migration of the humeral head. Methods The study population was retrospectively recruited from patients who underwent unilateral arthroscopic repair of isolated degenerative full-thickness SST tears between January 2017 and December 2019. Patients were divided into 2 subgroups based on whether they underwent LHB tenotomies during arthroscopy. While 37 patients underwent arthroscopic single-row SST repair, the other 33 patients underwent arthroscopic single-row SST repair with LHB tenotomy. The subject group consisted of people who had undergone arthroscopic shoulder surgery. Contralateral shoulders without rotator cuff injuries were included in the control group. The AHD and SST thicknesses of patients were examined via the ultrasound in both groups and subgroups. Results The mean age in the SST repair group was 55.52 ± 4.58 years (range, 46-63 years), whereas it was 58.24 ± 3.98 (range, 52-73 years) in the SST repair + LHB tenotomy group. In the SST repair group, 57.6% of patients were female and 42.4% were male, whereas 56.8% and 43.2% were in the SST repair + LHB tenotomy group, respectively. The mean body mass index was 28.06 ± 1.31 kg/m2 (range, 25.7-31.2 kg/m2) in the SST repair group and 28.95 ± 1.79 kg/m2 in the SST repair + LHB tenotomy group. Groups were not different for sex, surgery side, dominant side, tear size, and follow-up time; however, the SST repair + LHB tenotomy group had significantly higher mean age and body mass index than the SST repaired group. The mean AHD value and SST thickness were significantly less in both the rotator cuff repair group and the rotator cuff repair + LHB tenotomy group compared to the healthy shoulder. The mean AHD value was significantly lower in the SST repaired + LHB tenotomy group than in the SST repair group (P = .02). Conclusion The AHD was narrowed in patients who underwent LHB tenotomy and radiologically demonstrated the depressor effect of the LHB tendon on the humeral head. As a secondary outcome, we demonstrated that regardless of tenotomy, AHD could not be restored in patients who underwent arthroscopic single-row SST repair.
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Affiliation(s)
- Mahmud Aydin
- Department of Orthopaedics, Haseki Training and Research Hospital, İstanbul, Turkey
| | - Sercan Capkin
- Department of Orthopaedics, Aksaray Universty Education Research Hospital, Aksaray, Turkey
| | - Serkan Surucu
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, USA
| | - Ridvan Karahasanoglu
- Department of Orthopaedics, Haseki Training and Research Hospital, İstanbul, Turkey
| | - Murat Yilmaz
- Department of Orthopaedics, Haseki Training and Research Hospital, İstanbul, Turkey
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Sethi P, Fares MY, Murthi A, Tokish JM, Abboud JA. The long head of the biceps tendon: a valuable tool in shoulder surgery. J Shoulder Elbow Surg 2023; 32:1801-1811. [PMID: 37245621 DOI: 10.1016/j.jse.2023.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 03/28/2023] [Accepted: 04/05/2023] [Indexed: 05/30/2023]
Abstract
ANATOMY AND FUNCTION The long head of the biceps tendon (LHBT) has different properties and characteristics that render it a valuable tool in the hands of shoulder surgeons. Its accessibility, biomechanical strength, regenerative capabilities, and biocompatibility allow it to be a valuable autologous graft for repairing and augmenting ligamentous and muscular structures in the glenohumeral joint. SHOULDER SURGERY APPLICATIONS Numerous applications of the LHBT have been described in the shoulder surgery literature, including augmentation of posterior-superior rotator cuff repair, augmentation of subscapularis peel repair, dynamic anterior stabilization, anterior capsule reconstruction, post-stroke stabilization, and superior capsular reconstruction. Some of these applications have been described meticulously in technical notes and case reports, whereas others may require additional research to confirm clinical benefit and efficacy. CONCLUSION This review examines the role of the LHBT as a source of local autograft, with biological and biomechanical properties, in aiding outcomes of complex primary and revision shoulder surgery procedures.
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Affiliation(s)
- Paul Sethi
- Orthopedic and Neurosurgical Specialists, ONS Foundation, Greenwich, CT, USA
| | - Mohamad Y Fares
- Division of Shoulder and Elbow Surgery, Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | - Anand Murthi
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA
| | - John M Tokish
- Department of Orthopedic Surgery, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Joseph A Abboud
- Division of Shoulder and Elbow Surgery, Rothman Orthopaedic Institute, Philadelphia, PA, USA.
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Diplock B, Hing W, Marks D. The long head of biceps at the shoulder: a scoping review. BMC Musculoskelet Disord 2023; 24:232. [PMID: 36978047 PMCID: PMC10044783 DOI: 10.1186/s12891-023-06346-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 03/20/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND This review aimed to explore the available literature to update our understanding of the long head of biceps (LHB) at the shoulder. Synthesise our findings to identify emergent themes and knowledge gaps to inform future research and management directions. METHODS PubMed, Embase, Cinahl, SportDiscus, CENTRAL, and Web of Science were searched from inception to 31st December 2021. Articles were included if they referenced adult participants > 18 years of age and were written in English. RESULTS 214 articles were included in the final analysis, and results were categorised into six emergent themes: (1) Anatomy - Normal anatomical variation of the biceps from aberrant origins, third and fourth accessory heads, and an absence of the LHB tendon (LHBT) are not necessarily benign, with shoulder pain and instability a commonly reported theme. (2) Function - Bicep's role in glenohumeral elevation and stability in healthy shoulders is minimal. In contrast, LHB has a more significant role in shoulder stability and humeral head depression in subjects with rotator cuff failure or an absent LHBT. (3) Pathology - There is an association between LHB tendinopathy, rotator cuff disease, LHBT instability and occult rotator cuff tears. Early recruitment and hyperactivity of the LHB in subjects with symptomatic rotator cuff tears and instability suggest a potential compensatory role. (4) Assessment - The limited diagnostic utility of special orthopaedic tests in assessing LHBT pathology was a consistent theme. The utility of magnetic resonance imaging and ultrasound to identify full-thickness tendon tears and instability of the LHBT was moderate to high. However, the utility of clinical tests and imaging may be underestimated due to arthroscopy's limitations in fully visualising the proximal LHBT. (5) Non-Surgical Management - Ultrasound-guided injections into the biceps sheath show greater accuracy and patient outcomes than blinded injections; however, the entry of injectate into the intraarticular glenohumeral joint may have unwanted complications. (6) Surgical management - For the surgical management of biceps pathology with or without rotator cuff pathology, both biceps tenodesis and tenotomy report similar improvements in pain without any significant adverse effect on strength or function. Tenodesis favoured higher overall constant scores and a lower incidence of Popeye deformity and cramping arm pain, with tenotomy trending to be more cost and time effective. For patients with a healthy LHBT, rotator cuff repair with adjunctive tenodesis or tenotomy fails to provide additional clinical improvements compared to rotator cuff repair in isolation. CONCLUSIONS The scoping review highlights the variability of biceps anatomy, which is not necessarily benign and suggests a minimal role of the LHB in shoulder elevation and stability in healthy individuals. In contrast, individuals with rotator cuff tears experience proximal humeral migration and demonstrate hyperactivity of the LHB, suggesting a potential compensation role. The observed prevalence of LHBT pathology with rotator cuff tears is well established; however, the cause-and-effect relationship between LHBT pathology and rotator cuff disease is undetermined. The diagnostic utility of clinical tests and imaging to exclude LHBT pathology may be understated due to the limitations of arthroscopy to visualise the proximal LHBT fully. Rehabilitation programs for the LHB are understudied. Similar post-surgical clinical outcomes are observed for tenodesis and tenotomy for biceps and rotator cuff-related shoulder pain. Subjects undergoing biceps tenodesis are less likely to have cramping arm pain and a Popeye deformity than patients undergoing biceps tenotomy. The significance of routine surgical removal of the LHBT and sequelae on rotator cuff tear progression to failure and long-term shoulder function is unknown, and further research is required. PRE-REGISTRATION OSF: https://osf.io/erh9m.
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Affiliation(s)
- Brendan Diplock
- Faculty of Health Sciences & Medicine, Bond University, Gold Coast, Australia.
| | - Wayne Hing
- Faculty of Health Sciences & Medicine, Bond University, Gold Coast, Australia
| | - Darryn Marks
- Faculty of Health Sciences & Medicine, Bond University, Gold Coast, Australia
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Kajiwara D, Ochiai N, Hashimoto E, Hirosawa N, Akimoto K, Nojima D, Shimada Y, Ise S, Ohtori S. Imaging and histological evaluation of the long head of the biceps tendon in the presence of different types of rotator cuff tears. BMC Musculoskelet Disord 2023; 24:230. [PMID: 36973696 PMCID: PMC10045614 DOI: 10.1186/s12891-023-06338-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 03/20/2023] [Indexed: 03/29/2023] Open
Abstract
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.
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Affiliation(s)
- Daisuke Kajiwara
- Department of Orthopedic Surgery, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-Ku, Chiba, 260-0856, Japan.
| | - Nobuyasu Ochiai
- Department of Orthopedic Surgery, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-Ku, Chiba, 260-0856, Japan
| | - Eiko Hashimoto
- Department of Orthopedic Surgery, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-Ku, Chiba, 260-0856, Japan
| | - Naoya Hirosawa
- Department of Orthopedic Surgery, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-Ku, Chiba, 260-0856, Japan
| | - Koji Akimoto
- Department of Orthopedic Surgery, Chiba Rosai Hospital, Chiba, Japan
| | - Daisuke Nojima
- Nojima Orthopedics and Internal Medicine Clinic, Tokyo, Japan
| | - Yohei Shimada
- Department of Orthopedic Surgery, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-Ku, Chiba, 260-0856, Japan
| | - Shohei Ise
- Department of Orthopedic Surgery, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-Ku, Chiba, 260-0856, Japan
| | - Seiji Ohtori
- Department of Orthopedic Surgery, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-Ku, Chiba, 260-0856, Japan
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Biceps Tenodesis Better Improves the Shoulder Function Compared with Tenotomy for Long Head of the Biceps Tendon Lesions: A Meta-Analysis of Randomised Controlled Trials. J Clin Med 2023; 12:jcm12051754. [PMID: 36902540 PMCID: PMC10003204 DOI: 10.3390/jcm12051754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 02/09/2023] [Accepted: 02/14/2023] [Indexed: 02/25/2023] Open
Abstract
PURPOSE Surgical options for long head of the biceps tendon (LHBT) lesions include tenotomy and tenodesis. This study aims to determine the optimal surgical strategy for LHBT lesions with updated evidence from randomised controlled trials (RCTs). METHODS Literature was retrieved from PubMed, Cochrane Library, Embase and Web of Science on 12 January 2022. Randomised controlled trials (RCTs) comparing the clinical outcomes of tenotomy and tenodesis were pooled in the meta-analyses. RESULTS Ten RCTs with 787 cases met the inclusion criteria, and were included in the meta-analysis. Constant scores (MD, -1.24; p = 0.001), improvement of Constant scores (MD, -1.54; p = 0.04), Simple Shoulder Test (SST) scores (MD, -0.73; p = 0.03) and improvement of SST (p < 0.05) were significantly better in patients with tenodesis. Tenotomy was associated with higher rates of Popeye deformity (OR, 3.34; p < 0.001) and cramping pain (OR, 3.36; p = 0.008]. No significant differences were noticed between tenotomy and tenodesis regarding pain (p = 0.59), American Shoulder and Elbow Surgeons (ASES) score (p = 0.42) and its improvement (p = 0.91), elbow flexion strength (p = 0.38), forearm supination strength (p = 0.68) and range of motion of shoulder external rotation (p = 0.62). Subgroup analyses showed higher Constant scores in all tenodesis types and significantly larger improvement of Constant scores regarding intracuff tenodesis (MD, -5.87; p = 0.001). CONCLUSIONS According to the analyses of RCTs, tenodesis better improves shoulder function in terms of Constant scores and SST scores, and reduces the risk of Popeye deformity and cramping bicipital pain. Intracuff tenodesis might offer the best shoulder function as measured with Constant scores. However, tenotomy and tenodesis provide similar satisfactory results for pain relief, ASES score, biceps strength and shoulder range of motion.
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Çakar B, Güney A, Güney B, Uzun E, Sekban H. The effect of biceps tenotomy on humeral migration and clinical outcomes in arthroscopic rotator cuff repair. J Exp Orthop 2022; 9:113. [PMID: 36447061 PMCID: PMC9708983 DOI: 10.1186/s40634-022-00550-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 11/09/2022] [Indexed: 12/02/2022] Open
Abstract
PURPOSE To evaluate the effect of biceps tenotomy on humeral migration and clinical outcomes in patients who underwent arthroscopic rotator cuff (RC) repair. METHODS This is a retrospective study of 60 patients who underwent arthroscopic RC repair. Patients were divided into two groups, whether they underwent concomitant biceps tenotomy or not. The group underwent concomitant biceps tenotomy, tenotomy ( +), or not, tenotomy (-). Clinical and functional outcomes were performed using the American Shoulder and Elbow Surgeons (ASES), the University of California-Los Angeles (UCLA) scoring system. Radiological evaluation was performed in X-rays and magnetic resonance imaging (MRI), measuring the acromiohumeral distance (AHD), humeral migration (HM) and upper migration index (UMI). RESULTS There was no significant difference between the groups in terms of patient characteristics. The follow-up period was 30.9 ± 8.7 months in the tenotomy ( +) group and 34.9 ± 8.2 months in the tenotomy (-) group with no significant difference. Postoperative ASES score improved significantly in the tenotomy ( +) group compared to the tenotomy (-) group (91.2 ± 4.7, 80.8 ± 18.7, respectively, p = 0.005). There was a significant difference in postoperative AHD, HM and UMI values (MRI; p = 0.003, p = 0.017, p = 0.025; X-ray; p = 0.049, p = 0.002, p = 0.010, respectively). The post-pre difference increase of AHD [MRI for tenotomy( +): 0.14 ± 0.86 and tenotomy(-): 0.91 ± 0.85, p = 0.001; X-ray for tenotomy( +): 0.61 ± 0.43 and tenotomy(-): 1.12 ± 0.7, p = 0.001] and UMI [MRI for tenotomy( +): 0.005 ± 0.05 and tenotomy(-): 0.04 ± 0.06, p = 0.006; X-ray for tenotomy( +): 0.01 ± .064 and tenotomy(-): 0.12 ± 0.37, p = 0.110] values were higher in the tenotomy (-) group compared to the tenotomy ( +) group while HM values decreased more in the tenotomy (-) group. [MRI for tenotomy ( +): -0.19 ± 1.07 and tenotomy (-): -0.79 ± 1.52, p = 0.079; X-ray for tenotomy ( +): -0.27 ± 0.54 and tenotomy (-): -1.006 ± 1.83, p = 0.040]. CONCLUSION After short-term follow-up, the humeral head was positioned higher in patients who underwent LHBT tenotomy compared to patients without tenotomy. However, it seems to affect clinical outcomes during this period positively. LEVEL OF EVIDENCE Level 3.
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Affiliation(s)
- Burak Çakar
- grid.411739.90000 0001 2331 2603Orthopedics and Traumatology Department of Erciyes University Medical Faculty Hospital, Kayseri, Turkey
| | - Ahmet Güney
- grid.411739.90000 0001 2331 2603Orthopedics and Traumatology Department of Erciyes University Medical Faculty Hospital, Kayseri, Turkey
| | - Betül Güney
- grid.411739.90000 0001 2331 2603Erciyes University Halil Bayraktar Vocational School, Kayseri, Turkey
| | - Erdal Uzun
- grid.411739.90000 0001 2331 2603Orthopedics and Traumatology Department of Erciyes University Medical Faculty Hospital, Kayseri, Turkey
| | - Hazım Sekban
- grid.513116.1Kayseri City Hospital, Kayseri, Turkey
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11
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Xu S, Field LD. Arthroscopic Identification and Management of Hourglass Biceps. Arthrosc Tech 2022; 11:e1123-e1126. [PMID: 35782846 PMCID: PMC9244851 DOI: 10.1016/j.eats.2022.02.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 02/09/2022] [Indexed: 02/03/2023] Open
Abstract
The hourglass biceps is a condition in which the intra-articular portion of the biceps tendon becomes inflamed and hypertrophies relative to the remaining tendon. This condition can be seen in association with rotator cuff and labral pathology and may lead to anterior shoulder pain. Diagnosis requires careful visualization and inspection of the biceps tendon during shoulder arthroscopy, as the presentation may be subtle. Surgical treatment includes tenotomy or tenodesis, depending on patient factors and surgeon preference.
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Affiliation(s)
- Shin Xu
- Mississippi Sports Medicine and Orthopaedic Center, Jackson, Mississippi, U.S.A
| | - Larry D. Field
- Mississippi Sports Medicine and Orthopaedic Center, Jackson, Mississippi, U.S.A.,Address correspondence to: Larry D. Field, M.D., Mississippi Sports Medicine and Orthopaedic Center, 1325 E. Fortification St., Jackson, MI 39202.
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12
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Ren YM, Duan YH, Sun YB, Yang T, Hou WY, Liu C, Tian MQ. mRNA and long non-coding RNA expression profiles of rotator cuff tear patients reveal inflammatory features in long head of biceps tendon. BMC Med Genomics 2022; 15:140. [PMID: 35725478 PMCID: PMC9210618 DOI: 10.1186/s12920-022-01292-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 06/15/2022] [Indexed: 02/06/2024] Open
Abstract
Background This study aimed to identify the differentially expressed mRNAs and lncRNAs in inflammatory long head of biceps tendon (LHBT) of rotator cuff tear (RCT) patients and further explore the function and potential targets of differentially expressed lncRNAs in biceps tendon pathology. Methods Human gene expression microarray was made between 3 inflammatory LHBT samples and 3 normal LHBT samples from RCT patients. GO analysis and KEGG pathway analysis were performed to annotate the function of differentially expressed mRNAs. The real-time quantitative reverse transcription-polymerase chain reaction (qRT-PCR) was admitted to verify their expression. LncRNA-mRNA co-expression network, cis-acting element, trans-acting element and transcription factor (TF) regulation analysis were constructed to predict the potential molecular regulatory mechanisms and targets for LHB tendinitis. Results 103 differentially expressed lncRNAs and mRNAs, of which 75 were up-regulated and 28 were down-regulated, were detected to be differentially expressed in LHBT. The expressions of 4 most differentially expressed lncRNAs (A2MP1, LOC100996671, COL6A4P, lnc-LRCH1-5) were confirmed by qRT-PCR. GO functional analysis indicated that related lncRNAs and mRNAs were involved in the biological processes of regulation of innate immune response, neutrophil chemotaxis, interleukin-1 cell response and others. KEGG pathway analysis indicated that related lncRNAs and mRNAs were involved in MAPK signaling pathway, NF-kappa B signaling pathway, cAMP signaling pathway and others. TF regulation analysis revealed that COL6A4P2, A2MP1 and LOC100996671 target NFKB2. Conclusions LlncRNA-COL6A4P2, A2MP1 and LOC100996671 may regulate the inflammation of LHBT in RCT patients through NFKB2/NF-kappa B signaling pathway, and preliminarily revealed the pathological molecular mechanism of tendinitis of LHBT. Supplementary Information The online version contains supplementary material available at 10.1186/s12920-022-01292-y.
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Affiliation(s)
- Yi-Ming Ren
- Department of Joint and Sport Medicine, Tianjin Union Medical Center, Nankai University Affiliated People's Hospital, Jieyuan Road 190, Hongqiao District, Tianjin, 300121, People's Republic of China
| | - Yuan-Hui Duan
- Department of Joint and Sport Medicine, Tianjin Union Medical Center, Nankai University Affiliated People's Hospital, Jieyuan Road 190, Hongqiao District, Tianjin, 300121, People's Republic of China
| | - Yun-Bo Sun
- Department of Joint and Sport Medicine, Tianjin Union Medical Center, Nankai University Affiliated People's Hospital, Jieyuan Road 190, Hongqiao District, Tianjin, 300121, People's Republic of China
| | - Tao Yang
- Department of Joint and Sport Medicine, Tianjin Union Medical Center, Nankai University Affiliated People's Hospital, Jieyuan Road 190, Hongqiao District, Tianjin, 300121, People's Republic of China
| | - Wei-Yu Hou
- Department of Joint and Sport Medicine, Tianjin Union Medical Center, Nankai University Affiliated People's Hospital, Jieyuan Road 190, Hongqiao District, Tianjin, 300121, People's Republic of China
| | - Chang Liu
- Schoole of Medicine, Nankai University, Tianjin, People's Republic of China
| | - Meng-Qiang Tian
- Department of Joint and Sport Medicine, Tianjin Union Medical Center, Nankai University Affiliated People's Hospital, Jieyuan Road 190, Hongqiao District, Tianjin, 300121, People's Republic of China.
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13
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The Lark Loop Used for Proximal Biceps Tenodesis: An All-Arthroscopic Technique. Arthrosc Tech 2022; 11:e1195-e1201. [PMID: 35936850 PMCID: PMC9353156 DOI: 10.1016/j.eats.2022.02.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 02/17/2022] [Indexed: 02/03/2023] Open
Abstract
Long head of the biceps tendinopathy is a common shoulder problem that is difficult to diagnose and treat. Biceps tenodesis is an effective surgical approach target for long head of the biceps tendon lesions. This article describes an all-arthroscopic proximal biceps tenodesis technique. This technique uses a high-strength suture to construct a tear-resistant loop; fixation is achieved with a suture anchor at the proximal aspect of the intertubercular groove or the greater tuberosity. This tenodesis fixation is simple, with no neurovascular injury or humeral fracture risk. In addition, our technique is cost-effective, with no need for specialty sutures.
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14
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Ihsan Kilic A, Hapa O, Ozmanevra R, Demirhan Demirkiran N, Gursan O. Biceps tenodesis combined with rotator cuff repair increases functional status and elbow strength. J Orthop Surg (Hong Kong) 2022; 29:23094990211056978. [PMID: 34898325 DOI: 10.1177/23094990211056978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE The aim of the present study was to prospectively evaluate the elbow flexion and supination strengths and the functional outcomes of patients following arthroscopic rotator cuff repair combined with simultaneous biceps tenodesis. METHODS 19 patients who underwent arthroscopic rotator cuff repair and biceps tenodesis with at least 24 months of follow-up were included. Patients were evaluated using a visual analog scale (VAS) for bicipital groove pain, American Shoulder and Elbow Surgeons (ASES), and constant scores (CS), biceps apex distance (BAD), elbow flexion, and supination strengths. RESULTS The VAS for biceps groove measurement averages in the postoperative 6th, 12th, and 24th months was lower in comparison to preoperative data and was considered to be statistically significant (p < .05). The constant score, an average of all postoperative measurements and scores, was found to be higher than preoperative values and was considered to be statistically significant (p < .01). There was a significant difference in the operated and non-operated forearm supination and elbow flexion muscle strength measurements at the postoperative 3- and 6-month follow-ups (p < .01). CONCLUSION Arthroscopic biceps tenodesis into the anchors of the lateral row in combination with rotator cuff repair provides an increase in the strength of elbow flexion and forearm supination, while decreasing pain. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Ali Ihsan Kilic
- Department of Orthopaedics and Traumatology, Siirt State Hospital, Siirt, Turkey
| | - Onur Hapa
- Department of Orthopaedics and Traumatology, 064073University of Dokuz Eylül, Izmir, Turkey
| | - Ramadan Ozmanevra
- Department of Orthopaedics and Traumatology, 530180University of Kyrenia, Kyrenia, Turkish Republic of Northern Cyprus
| | - Nihat Demirhan Demirkiran
- Department of Orthopaedics and Traumatology, 552615Kütahya Health Sciences University School of Medicine, Kütahya, Turkey
| | - Onur Gursan
- Department of Orthopaedics and Traumatology, 064073University of Dokuz Eylül, Izmir, Turkey
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15
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Patel BH, Agarwalla A, Lu Y, Ouillette RJ, Forsythe B, Amin NH, Romeo AA, Liu JN. Isolated Biceps Tenodesis and Tenotomy: A Systematic Review of Indications and Patient Satisfaction. Orthopedics 2021; 44:333-340. [PMID: 34618647 DOI: 10.3928/01477447-20211001-04] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
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. 2021;44(6):333-340.].
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16
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Pérez-de la Cruz S. Use of a Portable Inertial Measurement Unit as an Evaluation Method for Supraspinatus Muscle: Proposed Normative Values. SENSORS 2021; 21:s21227723. [PMID: 34833798 PMCID: PMC8625058 DOI: 10.3390/s21227723] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 11/10/2021] [Accepted: 11/14/2021] [Indexed: 11/21/2022]
Abstract
Treatment protocols do not specify an appropriate weight for rehabilitating the shoulder joint. The purpose of this study was to establish normative values for the shoulder abduction range of motion and recommended weights to be used in the rehabilitation process after injury to the supraspinatus muscle. Fifty-eight volunteers were assessed using the DyCare system. A test was conducted by lifting the arm to a 90° angle and having the participants lift different weights. The range of motion was similar for both sexes, suggesting that sex had no influence on this variable. Regarding the use of weights, men did not show as much stability in their movement execution, with a high dispersion seen in values between zero and three kilograms of weight, reaching a maximum weight of six kilograms. However, women showed good joint stability from the beginning of the test, with values that remained constant as weight increased up to a maximum of five kilograms. In conclusion, no major differences were observed in supraspinatus muscle injury recovery according to sex. However, differences were observed in the amount of weight that was necessary and appropriate to allow the participants to recover their muscular strength and avoid relapses.
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Affiliation(s)
- Sagrario Pérez-de la Cruz
- Department of Nursing, Physical Therapy and Medicine, University of Almería, La Cañada de San Urbano, 04120 Almería, Spain
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17
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Panico L, Roy T, Namdari S. Long Head of the Biceps Tendon Ruptures: Biomechanics, Clinical Ramifications, and Management. JBJS Rev 2021; 9:01874474-202110000-00007. [PMID: 34695033 DOI: 10.2106/jbjs.rvw.21.00092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» Pathology of the long head of the biceps tendon is a common source of shoulder pain and often occurs in combination with other shoulder disorders. » Nonsurgical management, including rest and activity modification, use of nonsteroidal anti-inflammatory drugs, physical therapy, and corticosteroid injections, is usually the first line of treatment. » Patients with symptoms that are refractory to nonsurgical management are indicated for biceps tenotomy or various tenodesis procedures. » Although several studies have reported a higher incidence of "Popeye" deformity, muscle cramping, and pain in the bicipital groove postoperatively with tenotomy compared with tenodesis, there are no substantial differences in functional scores or patient satisfaction between the 2 techniques. » To date, both tenotomy and tenodesis have been shown to be effective options in the management of long head of the biceps tendinopathy, and there are advantages to each procedure.
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Affiliation(s)
- Leighann Panico
- Department of Orthopedic Surgery, UPMC Pinnacle, Harrisburg, Pennsylvania
| | - Trinava Roy
- Rowan University School of Osteopathic Medicine, Stratford, New Jersey
| | - Surena Namdari
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania
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18
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O'Brien MJ. Editorial Commentary: Shoulder Biceps Tenotomy Versus Tenodesis Surgical Decision Making Must be Individualized for Each Patient. Arthroscopy 2021; 37:1777-1778. [PMID: 34090564 DOI: 10.1016/j.arthro.2021.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 03/04/2021] [Indexed: 02/02/2023]
Abstract
The optimal treatment for proximal biceps tendon lesions identified at the time of arthroscopic rotator cuff repair remains a topic for debate. The decision between biceps tenotomy and tenodesis is one in which we will likely never have a clear-cut answer. Proponents of biceps tenotomy and biceps tenodesis will cite the pros and cons of each surgical option to support their treatment of choice. Several meta-analyses have shown no superior outcomes with either treatment. Cost analysis and surgical efficiency may favor biceps tenotomy, whereas the possible development of a Popeye deformity, biceps cramping, and supination strength favor tenodesis. The surgical treatment of choice requires an informed discussion and shared decision making between surgeon and patient to determine patients' expectations and maximize surgical outcomes for each individual patient.
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19
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DeFroda SF, Li L, Milner J, Bokshan SL, Owens BD. Cost comparison of arthroscopic rotator cuff repair with arthroscopic vs. open biceps tenodesis. J Shoulder Elbow Surg 2021; 30:340-345. [PMID: 32562763 DOI: 10.1016/j.jse.2020.05.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 05/15/2020] [Accepted: 05/18/2020] [Indexed: 02/01/2023]
Abstract
PURPOSE To use a nationwide database to determine differences in cost between patients who underwent arthroscopic rotator cuff tear with open vs. arthroscopic biceps tenodesis (BT). METHODS The 2014 State Ambulatory Surgical and Services Databases from 6 US states was utilized. All cases with CPT codes 29827 (arthroscopic rotator cuff repair [RCR]) and either 23430 (tenodesis of long tendon of biceps) or 29828 (arthroscopic BT) were selected. Cases that included both 23430 and 29828 were excluded, as were those missing demographic data. Generalized linear models were used to model costs based on the surgical and patient variables that were significant in the initial bivariate analysis (P < .05). RESULTS A total of 3635 RCR and BT cases were identified. There were 2847 (78.3%) with arthroscopic BT and 788 (21.7%) with open BT. Patients undergoing arthroscopic BT were 3.1 years older than patients undergoing open BT (P < .001). For arthroscopic BT, 39.2% of the cases were women compared with 22.6% of the open cases (P < .001). For operative variables, arthroscopic BT required 9 fewer minutes in the OR than open cases (P = .002). Concomitant distal clavicle resection was performed in 35.5% of arthroscopic BT cases compared with 29.8% of open cases (P = .004). While controlling for other significant factors, open BT was associated with $5542 lower costs than arthroscopic BT in the setting of RCR (P < .001). In either case, concomitant subacromial decompression added $10,669 (P < .001), and distal clavicle resection added $3210 (P < .001). High-volume surgical facilities were associated with $4107 lower costs (P < .001). CONCLUSIONS In a large series of patients undergoing arthroscopic RCR with open vs. arthroscopic BT, open BT was associated with $5542 lower costs than arthroscopic. Given that both techniques have been shown to be similarly effective in long-term follow-up, surgeons should be aware of opportunities for cost saving, particularly with the advent of bundled surgical reimbursements.
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Affiliation(s)
- Steven F DeFroda
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, Providence, RI, USA.
| | - Lambert Li
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, Providence, RI, USA
| | - John Milner
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, Providence, RI, USA
| | - Steven L Bokshan
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, Providence, RI, USA
| | - Brett D Owens
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, Providence, RI, USA
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20
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Ayoubi R, Darwish M, Nassour N, Aouad D, Maalouly J, Kanj V, El Rassi G. A rare case of an anatomical variation of bilateral long head of the biceps brachii tendons identified within the substance of bifid subscapularis tendons. Asia Pac J Sports Med Arthrosc Rehabil Technol 2021; 23:18-21. [PMID: 33376677 PMCID: PMC7744595 DOI: 10.1016/j.asmart.2020.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 09/03/2020] [Accepted: 09/03/2020] [Indexed: 11/09/2022] Open
Abstract
The long head of the biceps tendon is stabilized in the intertubercular groove by several anatomical structures. Dislocation or identification of the biceps tendon into or within the subscapularis tendon is very rarely mentioned in the literature. This is the first reported case of bilateral identification of the long head of the biceps tendons within the lateral subscapularis tendon. This report presents the case of a 51-year-old male patient who presented for bilateral shoulder pain. After failure of conservative treatment, MRIs were done which identified bilateral biceps tendons within the subscapularis tendons, with a concomitant supraspinatus tear on the right side. He underwent right shoulder arthroscopic biceps tenotomy, with supraspinatus repair. The symptoms of the left shoulder diminished as a result of the continuation of conservative treatment. The long head of the biceps tendon normally travels through the intertubercular groove and is stabilized by soft tissue and bony structures. Medial dislocation of the tendon is affected by the medial wall angle and by the integrity of the soft tissue stabilizers; most importantly the coracohumeral ligament in the proximal part of the groove. Dislocation of the biceps tendon into the substance of the subscapularis has been rarely mentioned in the literature; and as far as we know, bilateral occurrence without any identifiable subscapularis tears has never been previously mentioned. The bilateral occurrence with the absence of subscapularis lesions indicates that this is a congenital anomaly.
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21
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Zabrzyński J, Huri G, Gryckiewicz S, Çetik RM, Szwedowski D, Łapaj Ł, Gagat M, Paczesny Ł. Biceps Tenodesis versus Tenotomy with Fast Rehabilitation Protocol-A Functional Perspective in Chronic Tendinopathy. J Clin Med 2020; 9:jcm9123938. [PMID: 33291804 PMCID: PMC7762032 DOI: 10.3390/jcm9123938] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 11/21/2020] [Accepted: 12/03/2020] [Indexed: 12/17/2022] Open
Abstract
The study aimed to evaluate the results after arthroscopic tenodesis and tenotomy of the biceps tendon (LHBT), coupled in tenotomy modality with a personalized postoperative rehabilitation protocol. The study included patients who underwent arthroscopic biceps tenotomy or tenodesis due to chronic biceps tendinopathy. Postoperatively, a standard rehabilitation program was prescribed to the tenodesis group and personalized was introduced in the tenotomy group, respectively. The outcomes were assessed using the American Shoulder and Elbow Surgeons scale (ASES), clinical tests that are dedicated to biceps tendinopathy, the occurrence of a Popeye deformity, night pain, and return to previous sporting activities. A cohort of 67 patients was enrolled in the final follow-up examination (mean 27 months) of which 40 patients underwent tenotomy (60%), and 27 patients (40%) underwent tenodesis. The mean ASES score improved from 48.1 to 87.8 in the tenotomy group and from 44 to 72.7 in the tenodesis group during the follow-up (p < 0.0001). The tenotomy group had better mean postoperative ASES scores than the tenodesis group (p < 0.0001). Positive clinical tests for biceps pathology were noticed more often in patients after LHB tenodesis (p = 0.0541). The Popeye deformity occurred more often in the tenotomy group; however, no patient complained of the visual appearance of the arm contour (p = 0.0128). Moreover, the frequency of night pain decreased in the tenotomy group (p = 0.0059). Return to previous sporting activities was more frequent in the tenotomy group (p = 0.0090). Arthroscopic biceps tenotomy is a reproducible, simple procedure, and augmented by a rapid rehabilitation protocol that provides promising clinical outcomes, reduces shoulder pain, and allows the patient to return to previous sporting activities, even in population older than 50 years.
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Affiliation(s)
- Jan Zabrzyński
- Department of General Orthopaedics, Musculoskeletal Oncology and Trauma Surgery, University of Medical Sciences, 61-712 Poznań, Poland;
- Citomed Healthcare Center, Department of Orthopaedics, Orvit Clinic, Sklodowskiej 73, 87-100 Toruń, Poland; (S.G.); (D.S.); (Ł.P.)
- Department of Histology and Embryology, Faculty of Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, 85-067 Bydgoszcz, Poland;
- Correspondence: ; Tel.: +48-787-787-246
| | - Gazi Huri
- Orthopaedics and Traumatology Department, Hacettepe Universitesi, 06100 Ankara, Turkey; (G.H.); (R.M.Ç.)
| | - Szymon Gryckiewicz
- Citomed Healthcare Center, Department of Orthopaedics, Orvit Clinic, Sklodowskiej 73, 87-100 Toruń, Poland; (S.G.); (D.S.); (Ł.P.)
| | - Rıza Mert Çetik
- Orthopaedics and Traumatology Department, Hacettepe Universitesi, 06100 Ankara, Turkey; (G.H.); (R.M.Ç.)
| | - Dawid Szwedowski
- Citomed Healthcare Center, Department of Orthopaedics, Orvit Clinic, Sklodowskiej 73, 87-100 Toruń, Poland; (S.G.); (D.S.); (Ł.P.)
- Orthopaedic Arthroscopic Surgery International (OASI) Bioresearch Foundation, 20133 Milan, Italy
| | - Łukasz Łapaj
- Department of General Orthopaedics, Musculoskeletal Oncology and Trauma Surgery, University of Medical Sciences, 61-712 Poznań, Poland;
| | - Maciej Gagat
- Department of Histology and Embryology, Faculty of Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, 85-067 Bydgoszcz, Poland;
| | - Łukasz Paczesny
- Citomed Healthcare Center, Department of Orthopaedics, Orvit Clinic, Sklodowskiej 73, 87-100 Toruń, Poland; (S.G.); (D.S.); (Ł.P.)
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22
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Vopat ML, Yang SY, Gregor CM, Kallail KJ, Saunders BM. Medial Dislocation of the Long Head of the Biceps without Concomitant Subscapularis Tear: A Case Report. J Orthop Case Rep 2020; 9:6-10. [PMID: 32548018 PMCID: PMC7276595 DOI: 10.13107/jocr.2019.v09.i06.1564] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction Medial dislocation of the long head of the biceps tendon (LHBT) is classically known as a pathognomonic finding for a subscapularis or at least a rotator cuff (RC) injury. However, this case report outlines a young active individual with symptomatic medial dislocation of the long head of the biceps with associated posterior instability, without a corresponding RC injury. Case Report An 18-year-old male complained of the left shoulder pain and crepitus after a shoulder injury while playing hockey a year prior. Magnetic resonance imaging demonstrated medial dislocation of the LHBT without subscapularis or supraspinatus tendon injury. The patient complained of instability in the shoulder and exam findings supported posterior instability of the glenohumeral joint. Arthroscopic debridement of the glenohumeral joint with arthroscopic posterior capsulorrhaphy and open biceps tenodesis was performed. The patient regained full and painless range of motion at 2-year follow-up. Conclusion Medial dislocation of the LHBT can occur without injury to the subscapularis tendon. Furthermore, a capsulorrhaphy with open biceps tenodesis and closure of the rotator interval may provide a successful outcome for this rare injury pattern.
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Affiliation(s)
- Matthew L Vopat
- Department of Orthopaedic Surgery, University of Kansas School of Medicine-Wichita, Wichita, Kansas.,United States,KS
| | - Shang-You Yang
- Department of Orthopaedic Surgery, University of Kansas School of Medicine-Wichita, Wichita, Kansas.,United States,KS.,Department of Biological Sciences, Wichita State University, Wichita, KansasKS .,United States
| | - Cole Mc Gregor
- Department of Orthopaedic Surgery, University of Kansas School of Medicine-Wichita, Wichita, Kansas.,United States,KS
| | - K James Kallail
- Department of Orthopaedic Surgery, University of Kansas School of Medicine-Wichita, Wichita, Kansas.,United States,KS
| | - Bradley M Saunders
- Department of Orthopaedic Surgery, University of Kansas School of Medicine-Wichita, Wichita, Kansas.,United States,KS.,Via Christi Clinic, Wichita, KansasKS., United States
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23
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Yiannakopoulos CK, Megaloikonomos PD, Foufa K, Gliatis J. Ultrasound-guided versus palpation-guided corticosteroid injections for tendinosis of the long head of the biceps: A randomized comparative study. Skeletal Radiol 2020; 49:585-591. [PMID: 31712838 DOI: 10.1007/s00256-019-03315-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 09/04/2019] [Accepted: 09/06/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare accuracy, patient discomfort, and clinical outcome of ultrasound-guided versus palpation-guided corticosteroid injections to the bicipital groove in patients with long head of biceps (LHB) tendinosis. MATERIALS AND METHODS Forty-four patients with primary LHB tendinosis were randomized into two groups (group A, n = 22; group B, n = 22). All patients underwent treatment with a single corticosteroid injection to the bicipital groove. Injections in group A were performed under ultrasound-guidance, while in group B using a palpation-guided technique. The duration of each procedure was recorded. To assess accuracy, ultrasound examination was performed in both groups after injection. Patient discomfort was evaluated with visual analogue scale (VAS) for pain. The clinical outcome was assessed comparing the VAS, the Single Assessment Numeric Evaluation (SANE) score and the QuickDASH score before treatment and after 4 weeks and 6 months. RESULTS The mean duration of the procedure was 64 ± 6.87 s in group A and 81.91 ± 8.42 s in group B (p < 0.001). Injection accuracy in group A was 100% and in group B 68.18%. Discomfort was lower in group A, as compared to group B (22.10 vs. 35.50; p < 0.001). Symptoms, as measured by VAS, SANE and QuickDASH scores, improved in both groups at 4 weeks and 6 months (p < 0.05). Superior clinical improvement was recorded in group A in both time points (p < 0.05). CONCLUSIONS Corticosteroid injections are an effective treatment for primary LHB tendinosis. Under ultrasound guidance, injections to the bicipital groove are faster and produce lower discomfort. Superior accuracy and clinical outcomes can be achieved using the ultrasound-guided technique. LEVEL OF EVIDENCE Level II; Prospective Randomized Comparative Study.
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Affiliation(s)
- Christos K Yiannakopoulos
- Department of Arthroscopic and Shoulder Surgery, Metropolitan General Hospital, Athens, Greece.,Department of Sports Medicine & Exercise Biology, School of Physical Education and Sport Science, National and Kapodistrian, University of Athens, Athens, Greece
| | - Panayiotis D Megaloikonomos
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, ATTIKON University General Hospital, Athens, Greece.
| | | | - John Gliatis
- Department of Orthopaedics, University of Patras, Patras, Greece
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24
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Li D, Wang W, Liu Y, Ma X, Huang S, Qu Z. The backward traction test: a new and effective test for diagnosis of biceps and pulley lesions. J Shoulder Elbow Surg 2020; 29:e37-e44. [PMID: 31526561 DOI: 10.1016/j.jse.2019.07.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Revised: 06/25/2019] [Accepted: 07/01/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND The value of physical examination for diagnosis of lesions of the long head of the biceps (LHB) and the pulley remains unsatisfactory. The purpose of this study was to describe a new diagnostic test, the backward traction (BT) test, to detect lesions of the LHB and the biceps pulley. METHODS A prospective study of 143 patients was performed to evaluate the diagnostic value of the BT test and 2 traditional clinical tests (Speed and Yergason tests). Shoulder arthroscopy was used as the "gold standard." RESULTS For the detection of LHB injury, the BT test was the most sensitive (74%) and accurate (68%). The BT test had a higher diagnostic value for pulley lesions, with a high sensitivity of 81% and an accuracy of 71%. No significant differences in terms of specificity for LHB and pulley lesions were observed between tests. Regarding pulley lesions, the internally rotated and externally rotated BT test positions had high specificity for the diagnosis of specific anteromedial and posterolateral pulley lesions (79% and 73%, respectively). The BT test had a high κ coefficient of 0.768-0.811. CONCLUSION The BT test is more sensitive and accurate as a new test for LHB and pulley lesions and also specific to distinguish the medial sling and lateral sling lesions of the pulley.
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Affiliation(s)
- Danmei Li
- Department of Sports Medicine, The Affiliated Zhongshan Hospital of Dalian University, Dalian, China
| | - Weiming Wang
- Department of Sports Medicine, The Affiliated Zhongshan Hospital of Dalian University, Dalian, China.
| | - Yupeng Liu
- Department of Sports Medicine, The Affiliated Zhongshan Hospital of Dalian University, Dalian, China
| | - Xiaojun Ma
- Department of Sports Medicine, The Affiliated Zhongshan Hospital of Dalian University, Dalian, China
| | - Shibo Huang
- Department of Sports Medicine, The Affiliated Zhongshan Hospital of Dalian University, Dalian, China
| | - Zhenan Qu
- Department of Sports Medicine, The Affiliated Zhongshan Hospital of Dalian University, Dalian, China
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25
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Almeida A, Gobbi LF, de Almeida NC, Agostini AP, Garcia AF. PREVALENCE OF POPEYE DEFORMITY AFTER LONG HEAD BICEPS TENOTOMY AND TENODESIS. ACTA ORTOPEDICA BRASILEIRA 2019; 27:265-268. [PMID: 31839736 PMCID: PMC6901158 DOI: 10.1590/1413-785220192705216649] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective: To evaluate whether body mass index (BMI) 30 can be used as a cut-off point
in decisions about whether or not to perform long head biceps (LHB)
tenodesis, leading to a low rate of esthetic complaints, and to compare two
tenodesis techniques. Methods: Ninety-six patients underwent shoulder arthroscopy where tenotomy was
performed separately in patients with a BMI ≥30 and was followed by
tenodesis when BMI <30. The patients were assessed on the basis of their
personal perception of the deformity and by 3 independent observers. Results: The patient's perception of esthetic deformity in the arm was 15.6%. In the
tenotomy group (12.5%) and in the tenodesis group (17.9%) - (p = 0.476).
Patients with rocambole-like tenodesis perceived the deformity in 13.2% of
cases, while patients with anchor tenodesis noticed the deformity 27.8% (p =
0.263) of the time. There was no statistical difference in the perception of
deformity among the independent examiners. Conclusion: BMI 30 can be used as a cut-off point in decisions about whether or not to
perform LHB tenodesis, leading to low rates of esthetic complaint by
patients (12.5%). The rocambole-like tenodesis technique appears to be more
able to avoid esthetic deformity of the arm after the LHB tenotomy according
to the patients' observations. Level of evidence II, Prospective comparative study.
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26
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Belay ES, Wittstein JR, Garrigues GE, Lassiter TE, Scribani M, Goldner RD, Bean CA. Biceps tenotomy has earlier pain relief compared to biceps tenodesis: a randomized prospective study. Knee Surg Sports Traumatol Arthrosc 2019; 27:4032-4037. [PMID: 31486915 DOI: 10.1007/s00167-019-05682-1] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 08/19/2019] [Indexed: 11/24/2022]
Abstract
PURPOSE Surgical management for long head of the biceps (LHB) tendinopathy with either biceps tenotomy or tenodesis is a reliable, but debated treatment option. The aim of this prospective, randomized, single-blinded study is to evaluate differences in pain relief and subjective outcomes between biceps tenotomy versus tenodesis for LHB tendinopathy. METHODS Subjects were randomized and blinded to biceps tenotomy versus arthroscopic tenodesis intra-operatively. Outcomes evaluated included subjective patient outcome scores, pain, and cosmetic deformity. Subjective outcomes scores and pain were analyzed using a two-way ANOVA, controlling for concomitant rotator cuff repair. Binary outcomes were compared using Chi-square tests. RESULTS Thirty-four subjects (31 male, 3 female) with a median age of 56 (range 30-77) were enrolled. Twenty subjects were randomized to tenotomy and 14 to tenodesis. Fifty-six percent had concomitant rotator cuff repairs. The mean VAS pain score at 3 months was lower with tenotomy versus tenodesis. 2-year follow-up demonstrated no statistically significant differences for VAS, ASES, or SANE. 15/20 (75%) subjects with biceps tenotomy reported no pain medication use at the 2-week postoperative visit versus 5/14 (33%) for biceps tenodesis. Popeye deformity was found in 5/20 (25%) of tenotomy subjects versus 1/14 (7%) in tenodesis subjects. CONCLUSION Outcomes appear similar between biceps tenotomy versus tenodesis; however, the tenotomy group demonstrated greater incidence of cosmetic deformity but an earlier improvement in postoperative pain. LEVEL OF EVIDENCE Treatment Studies, Level II.
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Affiliation(s)
- Elshaday S Belay
- Department of Orthopaedic Surgery, Durham Veterans Affairs Medical Center, Duke University Medical Center, Box 3000, Durham, NC, 27710, UK.
| | - Jocelyn R Wittstein
- Department of Orthopaedic Surgery, Durham Veterans Affairs Medical Center, Duke University Medical Center, Box 3000, Durham, NC, 27710, UK
| | - Grant E Garrigues
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, USA
| | - Tally E Lassiter
- Department of Orthopaedic Surgery, Durham Veterans Affairs Medical Center, Duke University Medical Center, Box 3000, Durham, NC, 27710, UK
| | - Melissa Scribani
- Center for Biostatistics, Bassett Research Institute, Cooperstown, USA
| | - Richard D Goldner
- Department of Orthopaedic Surgery, Durham Veterans Affairs Medical Center, Duke University Medical Center, Box 3000, Durham, NC, 27710, UK
| | - Christopher A Bean
- Department of Orthopaedic Surgery, Durham Veterans Affairs Medical Center, Duke University Medical Center, Box 3000, Durham, NC, 27710, UK
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27
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Thoomes-de Graaf M, Ottenheijm RPG, Verhagen AP, Duijn E, Karel YHJM, van den Borne MPJ, Beumer A, van Broekhoven J, Dinant GJ, Tetteroo E, Lucas C, Koes BW, Scholten-Peeters GGM. Agreement between physical therapists and radiologists of stratifying patients with shoulder pain into new treatment related categories using ultrasound; an exploratory study. Musculoskelet Sci Pract 2019; 40:1-9. [PMID: 30660988 DOI: 10.1016/j.msksp.2019.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 12/23/2018] [Accepted: 01/10/2019] [Indexed: 01/08/2023]
Abstract
STUDY DESIGN A systematic overview of the literature and an agreement study. OBJECTIVES The aim of this study is to explore the inter-professional agreement of diagnostic musculoskeletal ultrasound (DMUS) between physical therapists (PT) and radiologists, using a new classification strategy based upon the therapeutic consequences in patients with shoulder pain. BACKGROUND DMUS is frequently used by PTs, although the agreement regarding traditional diagnostic labels between PTs and radiologists is only fair. Nevertheless, DMUS could be useful when used as a stratifying-tool. METHODS First, a systematic overview of current evidence was performed to assess which traditional diagnostic labels could be recoded into new treatment related categories (referral to secondary care, corticosteroid injections, physical therapy, watchful waiting). Next, kappa values were calculated for these categories between PTs and radiologists. RESULTS Only three categories were extracted, as none of the traditional diagnostic labels were classified into the 'corticosteroid injection' category. Overall, we found moderate agreement to stratify patients into treatment related categories and substantial agreement for the category 'referral to secondary care'. Both categories 'watchful waiting' and 'indication for physical therapy' showed moderate agreement between the two professions. CONCLUSION Our results indicate that the agreement between radiologists and PTs is moderate to substantial when labelling is based on treatment consequences. DMUS might be able to help the PT to guide treatment, especially for the category 'referral to secondary care' as this showed the highest agreement. However, as this is just an explorative study, more research is needed, to validate and assess the consequences of this stratification classification for clinical care.
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Affiliation(s)
- M Thoomes-de Graaf
- Department of General Practice, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands; Research Group Diagnostics, Avans University of Applied Science, Breda, the Netherlands.
| | - R P G Ottenheijm
- Department of Family Medicine, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
| | - A P Verhagen
- Department of General Practice, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands; Department of Physiotherapy, Graduate School of Health, University of Technology Sydney, Sydney, Australia
| | - E Duijn
- Department of General Practice, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands; Research Group Diagnostics, Avans University of Applied Science, Breda, the Netherlands
| | - Y H J M Karel
- Department of General Practice, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands; Research Group Diagnostics, Avans University of Applied Science, Breda, the Netherlands
| | | | - A Beumer
- Department of Orthopaedic Surgery, AMPHIA Hospital, Breda, the Netherlands
| | | | - G J Dinant
- Department of Family Medicine, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
| | - E Tetteroo
- Department of Radiology, AMPHIA Hospital, Breda, the Netherlands
| | - C Lucas
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - B W Koes
- Department of General Practice, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - G G M Scholten-Peeters
- Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, the Netherlands
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McCrum CL, Alluri RK, Batech M, Mirzayan R. Complications of biceps tenodesis based on location, fixation, and indication: a review of 1526 shoulders. J Shoulder Elbow Surg 2019; 28:461-469. [PMID: 30573431 DOI: 10.1016/j.jse.2018.09.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 08/29/2018] [Accepted: 09/05/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Long head of the biceps tendon (LHBT) tenodesis is predominantly performed for 2 reasons: anterior shoulder pain (ASP) or structural reasons (partial tear, dislocation). METHODS Between 2006 and 2014, all cases of primary LHBT tenodesis performed at an integrated health care system were retrospectively reviewed. Complications were analyzed by tenodesis location (below or out of the groove [OOG] vs leaving tendon in the groove [ITG]), fixation method (soft tissue vs implant), and indication (preoperative ASP vs structural). RESULTS Among 1526 shoulders, persistent ASP did not differ by fixation method (11.0% for implant vs 12.8% for soft tissue, P = .550) or location (10.8% for OOG vs 12.9% for ITG, P = .472). Soft-tissue tenodesis cases had more frequent new-onset ASP (11.9% vs 2.6%, P < .001) and subjective weakness (8.50% vs 3.92%, P < .001) but less frequent revisions (0% vs 1.19%, P = .03) than implant tenodesis cases. No difference was found between ITG and OOG for persistent ASP (12.9% vs 10.8%, P = .550), new-onset ASP (6.5% vs 2.8%, P = .339), cramping (1.70% vs 2.31%, P = .737), deformity (4.72% vs 4.62%, P = .532), or subjective weakness (6.23% vs 4.32%, P = .334), but ITG cases had more revisions (1.51% vs 0.60%, P = .001). Among implant tenodesis cases, 1 shoulder (0.085%) sustained a fracture. CONCLUSION The overall complication rate of LHBT tenodesis was low. Of the shoulders, 10.8% to 12.9% continued to have ASP, regardless of whether the LHBT was left ITG. Soft-tissue tenodesis cases had higher rates of new-onset ASP and subjective weakness. No significant difference for tenodesis ITG or OOG was found in biceps-related complications.
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Affiliation(s)
- Christopher L McCrum
- Department of Orthopaedic Surgery, UT Southwestern Medical Center, Dallas, TX, USA
| | - R Kiran Alluri
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Michael Batech
- Department of Biostatistics, Programming & Research Database Services, Kaiser Permanente, Pasadena, CA, USA
| | - Raffy Mirzayan
- Department of Orthopaedic Surgery, Kaiser Permanente Southern California, Baldwin Park, CA, USA.
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29
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The "Double Lasso-Loop" Technique Used for Arthroscopic Proximal Biceps Tenodesis. Arthrosc Tech 2019; 8:e291-e300. [PMID: 31016125 PMCID: PMC6475644 DOI: 10.1016/j.eats.2018.11.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Accepted: 11/04/2018] [Indexed: 02/03/2023] Open
Abstract
Disorders of the long head biceps tendon are among the most challenging of shoulder problems to diagnose and manage. In this Technical Note, we introduce an arthroscopic technique for proximal biceps tenodesis high in the groove at the articular margin of the humeral head using a single anchor and 2 self-cinching loops followed by 5 alternating half-hitches to secure the construct. This method is simple and enables stable fixation of the biceps tendon.
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30
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Cua RCA, Hsiao MY. A Female Laborer with Right Anterior Shoulder Pain. J Med Ultrasound 2019; 26:229-230. [PMID: 30662160 PMCID: PMC6314100 DOI: 10.4103/jmu.jmu_37_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 06/06/2018] [Indexed: 11/24/2022] Open
Affiliation(s)
- Ronald Christopher A Cua
- Department of Physical Medicine and Rehabilitation, University of Santo Tomas Hospital, 1008 Metro Manila, Philippines, Taiwan
| | - Ming Yen Hsiao
- Departments of Physical Medicine and Rehabilitation, College of Medicine, National Taiwan University Hospital, National Taiwan University, Taipei, Taiwan
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31
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Hong CK, Yeh ML, Chang CH, Chiang FL, Jou IM, Wang PH, Su WR. Comparison of changes in shoulder functions between biceps tenotomy and tenodesis in an animal model. Asia Pac J Sports Med Arthrosc Rehabil Technol 2019; 15:17-22. [PMID: 30555792 PMCID: PMC6275213 DOI: 10.1016/j.asmart.2018.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 11/03/2018] [Accepted: 11/14/2018] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES Tenotomy and tenodesis of the long head of biceps tendon are effective pain-relieving treatments. However, there is no consensus on the functional outcome after these surgical procedures. We hypothesized that there would be no difference in ambulation parameters after recovery from the surgery between rats that underwent tenotomy versus tenodesis procedures. METHODS Twenty-four New Zealand rats were used and randomly divided into three groups. Each group received one of the following surgeries: tenotomy, tenodesis, and sham operation. A video-based walking track system was applied for gait analysis at day -1, 1, 3, 5, 7, 14 and 21 for each rat. Temporal and spatial parameters were obtained, and asymmetric index was calculated for each parameter. RESULTS Compared to the tenotomy and sham-operated groups, the rats in the tenodesis group had shorter stance phase, longer swing time, longer step length, smaller paw length, smaller intermediary toe-spread length, smaller toe-spread length, and larger foot angle right after the tenodesis procedure. After day 14, all parameters were equivalent to those of the sham-operated group. At the end of the study, there were no functional changes found in tenotomy and tenodesis groups compared with the sham-operated group and preoperative status. CONCLUSION Transient functional alterations in temporal and spatial parameters are found after tenotomy and tenodesis in a rat model. The functional changes in the tenodesis group existed for a longer period than in tenotomy group; however, and all parameters showed no significant differences when compared with the sham group at the conclusion of the study.
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Affiliation(s)
- Chih-Kai Hong
- Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ming-Long Yeh
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan
- Medical Device Innovation Center, National Cheng Kung University, Tainan, Taiwan
| | - Chih-Hsun Chang
- Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Florence L. Chiang
- School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - I-Ming Jou
- Department of Orthopedics, E-Da Hospital, I-Shou University, Taiwan
| | - Ping-Hui Wang
- Orthopedic Surgeon, Department of Orthopedics, Chi-Mei Medical Center, Tainan, Taiwan
| | - Wei-Ren Su
- Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Medical Device R & D Core Laboratory, National Cheng Kung University Hospital, Tainan, Taiwan
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32
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Chen M, Shetye S, Huegel J, Riggin CN, Gittings DJ, Nuss CA, Weiss SN, Kuntz AF, Soslowsky LJ. Biceps Detachment Preserves Joint Function in a Chronic Massive Rotator Cuff Tear Rat Model. Am J Sports Med 2018; 46:3486-3494. [PMID: 30419172 PMCID: PMC6563917 DOI: 10.1177/0363546518805091] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Lesions of the long head of the biceps tendon are often associated with massive rotator cuff tears (MRCTs), and biceps tenotomy is frequently performed for pain relief and functional reservation. However, the efficacy and safety of biceps tenotomy regarding the effects on the surrounding tissues in chronic MRCT are unclear. HYPOTHESIS Biceps tenotomy would result in improved mechanical and histological properties of the intact subscapularis tendon and improved in vivo shoulder function while not compromising glenoid cartilage properties. STUDY DESIGN Controlled laboratory study. METHODS Right supraspinatus and infraspinatus tendons were detached in 25 male Sprague-Dawley rats, followed by 4 weeks of cage activity to create a chronic MRCT condition. Animals were randomly divided into 2 groups and received either biceps tenotomy (n = 11) or sham surgery (n = 14) and were sacrificed 4 weeks thereafter. Forelimb gait and ground-reaction forces were recorded 1 day before the tendon detachment (baseline), 1 day before the surgical intervention (biceps tenotomy or sham), and 3, 7, 10, 14, 21, and 28 days after the intervention to assess in vivo shoulder joint function. The subscapularis tendon and glenoid cartilage were randomly allocated for mechanical testing or histologic assessment after the sacrifice. RESULTS Compared with sham surgery, biceps tenotomy partially restored the in vivo shoulder joint function, with several gait and ground-reaction force parameters returning closer to preinjury baseline values at 4 weeks. With biceps tenotomy, mechanical properties of the subscapularis tendons were improved, while mechanical properties and histological Mankin scores of the glenoid cartilage were not diminished when compared with the sham group. CONCLUSION Biceps tenotomy in the presence of chronic MRCT partially preserves overall shoulder function and potentially restores subscapularis tendon health without causing detrimental effects to joint cartilage. This laboratory study adds to the growing literature regarding the protective effects of biceps tenotomy on the shoulder joint in a chronic MRCT model. CLINICAL RELEVANCE This study provides important basic science evidence supporting the use of biceps tenotomy in patients with massive rotator cuff tears.
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Affiliation(s)
- Mengcun Chen
- McKay Orthopaedic Research Laboratory, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Snehal Shetye
- McKay Orthopaedic Research Laboratory, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Julianne Huegel
- McKay Orthopaedic Research Laboratory, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Corinne N. Riggin
- McKay Orthopaedic Research Laboratory, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Daniel J. Gittings
- McKay Orthopaedic Research Laboratory, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Courtney A. Nuss
- McKay Orthopaedic Research Laboratory, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Stephanie N. Weiss
- McKay Orthopaedic Research Laboratory, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew F. Kuntz
- McKay Orthopaedic Research Laboratory, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Louis J. Soslowsky
- McKay Orthopaedic Research Laboratory, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Abstract
The long head of the biceps brachii is a well-known "pain generator" in the shoulder. Biceps tendinitis, instability, and rupture encompass the majority of symptomatic lesions. Clinical diagnosis, particularly of biceps tendinitis, can be difficult, given the nonspecific physical examination findings. Treatment options are initially nonoperative, with surgical management reserved for specific presentations or refractory cases. In recent years, biceps tenodesis and tenotomy have become the mainstays of operative treatment. Management of biceps lesions must also involve consideration of other shoulder pathology, as they are often not an isolated finding. Although there remains debate on the best treatment options for long head of the biceps injuries, a review of current literature provides important principles that can help guide clinical decision making.
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34
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Katsuki S, Terayama H, Tanaka R, Qu N, Tanaka O, Umemoto K, Suyama K, Sakabe K. Variation in origin of the long head of the biceps brachii tendon in a cadaver: A case report. Medicine (Baltimore) 2018; 97:e10708. [PMID: 29768337 PMCID: PMC5976288 DOI: 10.1097/md.0000000000010708] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 04/18/2018] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION In general, the long head of the biceps brachii (LHB) tendon arises from the supraglenoid tubercle in the shoulder joint, and it has an important stabilizing mechanism for the humeral head in the shoulder joint. This case demonstrates that even if the LHB tendon can be palpated outside of the shoulder joint, it may disappear in the intertubercular sulcus (IS) and in the glenohumeral (GH) joint because of abnormal articulation. PATIENT CONCERNS This case involved the cadaver of an 82-year-old Japanese man (number 1936, cause of death: hepatocellular tumor), who was selected from the bodies used for gross anatomy practice at the Tokai University School of Medicine in 2017. INTERVENTION We removed the fat and skin around the shoulder joint for observational purposes and carefully examined the gross anatomy of the structures. DIAGNOSIS We suspected that the long head of the biceps brachii tendon arose from the lesser tubercle (LT) in the cadaver. In our case, it was found that the upper part of the subscapularis (SSC) tendon was torn first, and the succeeding degenerative changes and rupture of the LHB tendon were intra-articular. OUTCOMES The long head of the biceps brachii tendon was found to be ruptured in the GH joint, and scar tissue developed between the distal stump of the tendon and the articular capsule, resulting in fusion with the LT. CONCLUSIONS This case necessitates confirmation that the LHB tendon is present in the IS and in the GH joint to treat cases wherein failure of the dynamic stabilizing mechanism for the humeral head occurs.
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Affiliation(s)
- Shuji Katsuki
- Department of Rehabilitation, Kanto Rosai Hospital, 1-1 Kizukisumiyoshi-cho, Nakahara-ku, Kawasaki-si
- Department of Anatomy, Division of Basic Medical Science, Tokai University School of Medicine, 143 Shimokasuya, Isehara-si, Kanagawa, Japan
| | - Hayato Terayama
- Department of Anatomy, Division of Basic Medical Science, Tokai University School of Medicine, 143 Shimokasuya, Isehara-si, Kanagawa, Japan
| | - Ryuta Tanaka
- Department of Rehabilitation, Kanto Rosai Hospital, 1-1 Kizukisumiyoshi-cho, Nakahara-ku, Kawasaki-si
- Department of Anatomy, Division of Basic Medical Science, Tokai University School of Medicine, 143 Shimokasuya, Isehara-si, Kanagawa, Japan
| | - Ning Qu
- Department of Anatomy, Division of Basic Medical Science, Tokai University School of Medicine, 143 Shimokasuya, Isehara-si, Kanagawa, Japan
| | - Osamu Tanaka
- Department of Anatomy, Division of Basic Medical Science, Tokai University School of Medicine, 143 Shimokasuya, Isehara-si, Kanagawa, Japan
| | - Kanae Umemoto
- Department of Anatomy, Division of Basic Medical Science, Tokai University School of Medicine, 143 Shimokasuya, Isehara-si, Kanagawa, Japan
| | - Kaori Suyama
- Department of Anatomy, Division of Basic Medical Science, Tokai University School of Medicine, 143 Shimokasuya, Isehara-si, Kanagawa, Japan
| | - Kou Sakabe
- Department of Anatomy, Division of Basic Medical Science, Tokai University School of Medicine, 143 Shimokasuya, Isehara-si, Kanagawa, Japan
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Abstract
Management of proximal and distal biceps tendon pathology is evolving. The long head of the biceps tendon, if inflamed, may be a pain-producing structure. In appropriately indicated patients, a symptomatic long head of the biceps tendon can be surgically managed via tenotomy, tenodesis, and/or superior labrum anterior to posterior repair. In some patients, primary superior labrum anterior to posterior pathology can be managed via biceps tenodesis. Determining which procedure is most appropriate and which technique and implant are preferred for a given patient with biceps tendon pathology is controversial. Less debate exists with regard to the timing of distal biceps tendon repair; however, considerable controversy exists with regard to selection of an appropriate surgical technique and implant. In addition, the treatment of patients with a chronic and/or retracted distal biceps tendon tear and patients in whom distal biceps tendon repair fails is extremely challenging. Orthopaedic surgeons should understand the anatomy of, nonsurgical and surgical treatment options for, and outcomes of patients with proximal or distal biceps tendon pathology.
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Effect of patient age on accuracy of primary MRI signs of long head of biceps tearing and instability in the shoulder: an MRI-arthroscopy correlation study. Skeletal Radiol 2018; 47:203-214. [PMID: 28983764 DOI: 10.1007/s00256-017-2783-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 09/15/2017] [Accepted: 09/24/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine the effect of patient age on the accuracy of primary MRI signs of long head of biceps (LHB) tendon tearing and instability in the shoulder using arthroscopy as a reference standard. MATERIALS AND METHODS Subjects with MRI studies and subsequent arthroscopy documenting LHB tendon pathology were identified and organized into three age groups (18-40, 41-60, 61-87). Normal and tendinopathic tendons were labeled grade 0, partial tears grade 1 and full tears grade 2. Two radiologists blinded to arthroscopic data graded MRI studies independently. Prevalence of disease, MRI accuracy for outcomes of interest, and inter-reader agreement were calculated. RESULTS Eighty-nine subjects fulfilled inclusion criteria with 36 grade 0, 36 grade 1 and 17 grade 2 tendons found at arthroscopy. MRI sensitivity, regardless of age, ranged between 67-86% for grade 0, 72-94% for grade 1 and 82-94% for grade 2 tendons. Specificity ranged between 83-96% for grade 0, 75-85% for grade 1 and 99-100% for grade 2 tendons. MRI accuracy for detection of each LHB category was calculated for each age group. MRI was found to be least sensitive for grade 0 and 1 LHB tendons in the middle-aged group with sensitivity between 55-85% for grade 0 and 53-88% for grade 1 tendons. Agreement between MRI readers was moderate with an unweighted kappa statistic of 62%. CONCLUSION MRI accuracy was moderate to excellent and agreement between MRI readers was moderate. MRI appears to be less accurate in characterizing lower grades of LHB tendon disease in middle-aged subjects.
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Smith CR, Yoon JT, Long JR, Friedman MV, Hillen TJ, Stensby JD. The Radiologist’s Primer to Imaging the Noncuff, Nonlabral Postoperative Shoulder. Radiographics 2018; 38:149-168. [DOI: 10.1148/rg.2018170061] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Christopher R. Smith
- From the Mallinckrodt Institute of Radiology, Musculoskeletal Section, Washington University School of Medicine, 510 S Kingshighway Blvd, Campus Box 8131, St Louis, MO 63110
| | - Jason T. Yoon
- From the Mallinckrodt Institute of Radiology, Musculoskeletal Section, Washington University School of Medicine, 510 S Kingshighway Blvd, Campus Box 8131, St Louis, MO 63110
| | - Jeremiah R. Long
- From the Mallinckrodt Institute of Radiology, Musculoskeletal Section, Washington University School of Medicine, 510 S Kingshighway Blvd, Campus Box 8131, St Louis, MO 63110
| | - Michael V. Friedman
- From the Mallinckrodt Institute of Radiology, Musculoskeletal Section, Washington University School of Medicine, 510 S Kingshighway Blvd, Campus Box 8131, St Louis, MO 63110
| | - Travis J. Hillen
- From the Mallinckrodt Institute of Radiology, Musculoskeletal Section, Washington University School of Medicine, 510 S Kingshighway Blvd, Campus Box 8131, St Louis, MO 63110
| | - James D. Stensby
- From the Mallinckrodt Institute of Radiology, Musculoskeletal Section, Washington University School of Medicine, 510 S Kingshighway Blvd, Campus Box 8131, St Louis, MO 63110
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Reference Values of Flexion and Supination in the Elbow Joint of a Cohort without Shoulder Pathologies. BIOMED RESEARCH INTERNATIONAL 2017; 2017:1654796. [PMID: 29204437 PMCID: PMC5674724 DOI: 10.1155/2017/1654796] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 08/30/2017] [Accepted: 09/14/2017] [Indexed: 11/21/2022]
Abstract
Background After surgery of the long head of the biceps tendon, the examination of the biceps brachii muscle function and strength is common clinical practice. The muscle strength is usually compared with the uninjured contralateral side or with a matched pair group assuming that the uninjured side can be used as an appropriate reference. Hypothesis/Purpose The purpose of this study was to define reference values of the supination and flexion strength in the elbow joint and to investigate the influence of the arm positions and various anthropometric factors. Methods 105 participants without any shoulder pathologies were enrolled. A full medical history was obtained and a physical examination was performed. The bilateral isometric testing included the supination torque in various forearm positions and elbow flexion strength with a custom engineered dynamometer. Multiple linear regression analysis was used to investigate the correlation of the strength and anthropometric factors. Results Only age and gender were significant supination and flexion strength predictors of the elbow. Hence, it was possible to calculate a gender-specific regression line for each forearm position to predict the age-dependent supination torque. The supination strength was greatest with the arm in 90° elbow flexion and the upper arm in full pronation.
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Desai SS, Mata HK. Long Head of Biceps Tendon Pathology and Results of Tenotomy in Full-Thickness Reparable Rotator Cuff Tear. Arthroscopy 2017; 33:1971-1976. [PMID: 28847573 DOI: 10.1016/j.arthro.2017.06.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 04/24/2017] [Accepted: 06/16/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To document the incidence of long head of the biceps tendon (LHBT) pathology in full-thickness reparable rotator cuff tears and report the clinical results of arthroscopic LHBT tenotomy combined with rotator cuff repair. METHODS Between January 2012 and January 2014, 141 shoulders with full-thickness rotator cuff tears that had undergone arthroscopic repair were included for the analysis. The LHBT was thoroughly examined during arthroscopy, and tenotomy was performed in all patients with a pathologic LHBT. Shoulder range of movement and the Constant score were recorded at an average follow-up of 2.2 years (range, 24-40 months). RESULTS The overall incidence of LHBT pathology was 36.1% (51 of 141 shoulders). The increase in LHBT pathology with the increase in the size of the rotator cuff tear was statistically significant (P = .001). Tears involving the subscapularis had a statistically significantly higher incidence of LHBT pathology (P = .001). The duration of the rotator cuff tear showed no statistical significance regarding the incidence of LHBT pathology (P = .598). Of 141 patients with full-thickness rotator cuff tears, 89 had tears due to trauma and 52 had atraumatic tears. The difference in the incidence of LHBT pathology between the traumatic and atraumatic groups was not statistically significant (P = .412). The average Constant score in the patients who had undergone LHBT tenotomy was 82 (range, 70-90), and in those with normal tendons, it was 84 (range, 72-92). The difference was not statistically significant (P = .423). CONCLUSIONS About one-third of patients with full-thickness reparable rotator cuff tears are likely to have LHBT pathology. Large and massive rotator cuff tears and tears involving the subscapularis are more likely to have LHBT pathology. Tenotomy of the pathologic LHBT as an adjunct to rotator cuff repair produces satisfactory results. LEVEL OF EVIDENCE Level IV, therapeutic case series.
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Affiliation(s)
- Sanjay S Desai
- Shoulder and Knee Clinic and Bhatia Hospital, Mumbai, India.
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Mirzayan R, Takara T, Batech M, McCrum CL. In Vivo Analysis of Biceps Tendon Characteristics in Subpectoral Tenodesis. Arthroscopy 2017; 33:1495-1502. [PMID: 28684148 DOI: 10.1016/j.arthro.2017.03.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 03/03/2017] [Accepted: 03/29/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To report the in vivo characteristics of the long head of the biceps tendon (LHBT); to evaluate the relation of age, gender, height, weight, and body mass index to the length and sutured and tubularized diameter of the LHBT; and to determine the smallest possible tunnel diameter for a subpectoral biceps tenodesis (SPBT) that can accommodate most patients. METHODS The study included 66 patients (33 men and 33 women) with an average age of 54 years (range, 29-73 years) undergoing SPBT. After tenotomy, the length from the biceps musculotendinous junction to the released end was measured. The tendon was transected 3 cm proximal to the musculotendinous junction and sutured, and the diameter was measured. The depth of the reamed tunnel was recorded. RESULTS The average tendon length was 84.0 mm, measuring 91.9 mm in men and 76.2 mm in women (P < .001), and the average tendon diameter was 4.4 mm, varying slightly between men (4.5 mm) and women (4.3 mm) (P < .001). Mean bone tunnel depth was 17.5 mm, with 19 mm in men and 16.1 mm in women (P < .001). Patient height showed a significant relation to both tendon length and tendon diameter. Weight was not correlated with tendon diameter but did show a significant relation to tendon length. CONCLUSIONS We have characterized the in vivo length and diameter of the LHBT at the time of an SPBT. Our findings have shown that there was a statistically significant gender difference in tendon length and diameter, but the diameter of the sutured tendon, which was placed into the tunnel, averaged 4.4 mm and ranged from 3.5 to 5 mm for all ages, both genders, all heights, and all weights. This finding is clinically relevant in that a small tunnel measuring 5.5 mm or less is sufficient to perform an SPBT. LEVEL OF EVIDENCE Level IV, case series, anatomic study.
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Affiliation(s)
- Raffy Mirzayan
- Department of Orthopaedic Surgery, Kaiser Permanente, Baldwin Park, California, U.S.A..
| | - Tadashi Takara
- Department of Orthopedic Surgery, Ventura County Medical Center, Ventura, California, U.S.A
| | - Michael Batech
- Department of Biostatistics, Programming & Research Database Services, Kaiser Permanente Southern California Research and Evaluation Department, Pasadena, California, U.S.A
| | - Christopher L McCrum
- Department of Orthopaedic Surgery, University of Pittsburgh Center for Sports Medicine, Pittsburgh, Pennsylvania, U.S.A
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Grassbaugh JA, Bean BR, Greenhouse AR, Yu HH, Arrington ED, Friedman RJ, Eichinger JK. Refuting the lipstick sign. J Shoulder Elbow Surg 2017; 26:1416-1422. [PMID: 28359698 DOI: 10.1016/j.jse.2017.01.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 01/03/2017] [Accepted: 01/19/2017] [Indexed: 02/01/2023]
Abstract
BACKGROUND Arthroscopic examination of the tendon has been described as the "gold standard" for diagnosis of tendinitis of the long head of the biceps (LHB). An arthroscopic finding of an inflamed and hyperemic LHB within the bicipital groove has been described as the "lipstick sign." Studies evaluating direct visualization in diagnosis of LHB tendinitis are lacking. METHODS During a 1-year period, 363 arthroscopic shoulder procedures were performed, with 16 and 39 patients prospectively selected as positive cases and negative controls, respectively. All positive controls had groove tenderness, positive Speed maneuver, and diagnostic ultrasound-guided bicipital injection. Negative controls had none of these findings. Six surgeons reviewed randomized deidentified arthroscopic pictures of enrolled patients The surgeons were asked whether the images demonstrated LHB tendinitis and if the lipstick sign was present. RESULTS Overall sensitivity and specificity were 49% and 66%, respectively, for detecting LHB tendinitis and 64% and 31%, respectively, for erythema. The nonweighted κ score for interobserver reliability ranged from 0.042 to 0.419 (mean, 0.215 ± 0.116) for tendinitis and from 0.486 to 0.835 (mean, 0.680 ± 0.102) for erythema. The nonweighted κ score for intraobserver reliability ranged from 0.264 to 0.854 (mean, 0.615) for tendinitis and from 0.641 to 0.951 (mean, 0.783) for erythema. CONCLUSIONS The presence of the lipstick sign performed only moderately well in a rigorously designed level III study to evaluate its sensitivity and specificity. There is only fair agreement among participating surgeons in diagnosing LHB tendinitis arthroscopically. Consequently, LHB tendinitis requiring tenodesis remains a clinical diagnosis that should be made before arthroscopic examination.
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Affiliation(s)
| | | | - Alyssa R Greenhouse
- Department of Orthopaedics, Medical University of South Carolina, Charleston, SC, USA
| | - Henry H Yu
- Madigan Army Medical Center, Tacoma, WA, USA
| | | | - Richard J Friedman
- Department of Orthopaedics, Medical University of South Carolina, Charleston, SC, USA
| | - Josef K Eichinger
- Department of Orthopaedics, Medical University of South Carolina, Charleston, SC, USA.
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Ribeiro FR, Ursolino APS, Ramos VFL, Takesian FH, Tenor Júnior AC, Costa MPD. Lesões do cabo longo do bíceps: tenotomia versus tenodese. Rev Bras Ortop 2017. [DOI: 10.1016/j.rbo.2016.05.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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Ribeiro FR, Ursolino APS, Ramos VFL, Takesian FH, Tenor Júnior AC, Costa MPD. Disorders of the long head of the biceps: tenotomy versus tenodesis. Rev Bras Ortop 2017; 52:291-297. [PMID: 28702386 PMCID: PMC5497000 DOI: 10.1016/j.rboe.2017.04.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 05/31/2016] [Indexed: 01/02/2023] Open
Abstract
Disorders of the long head of biceps tendon are common in clinical practice. Their causes could be degenerative, inflammatory, instability (subluxation or luxation) or traumatic. They are generally associated to other diseases of the shoulder, mainly rotator cuff injuries. Currently, there is controversy in the literature regarding the indications for surgical treatment and the choice of the best technique for each case, due to the possibility of esthetic deformity, loss of muscle strength, and residual pain. The objective of this study was to identify the indications for surgical treatment, the best surgical technique, and the advantages and disadvantages of each technique described in the orthopedic literature for the treatment of long head of biceps tendon injuries. A revision of the orthopedic medical literature on the following databases: Biblioteca Regional de Medicina (BIREME), Medline, PubMed, Cochrane Library and Google Scholar, comprising articles published in the period from 1991 to 2015.
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Affiliation(s)
- Fabiano Rebouças Ribeiro
- Hospital do Servidor Público Estadual de São Paulo, Departamento de Ortopedia, São Paulo, SP, Brazil
| | | | | | | | | | - Miguel Pereira da Costa
- Hospital do Servidor Público Estadual de São Paulo, Departamento de Ortopedia, São Paulo, SP, Brazil
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Webb N, Bravman J, Jensen A, Flug J, Strickland C. Arthrographic Anatomy of the Biceps Tendon Sheath: Potential Implications for Selective Injection. Curr Probl Diagn Radiol 2017; 46:415-418. [PMID: 28392204 DOI: 10.1067/j.cpradiol.2017.02.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 01/24/2017] [Accepted: 02/13/2017] [Indexed: 11/22/2022]
Abstract
The purpose of this investigation was to better define the anatomical features of the biceps tendon sheath, including the distance the sheath extends below the inferior margin of the subscapularis tendon and below the termination of the bony bicipital groove. A total of 110 magnetic resonance and computed tomography arthrograms performed during 1-year period at our institution were retrospectively reviewed, and the length of the biceps tendon sheath and distances from the inferior margin of the subscapularis tendon and from the termination of the bicipital groove to the inferior margin of the biceps tendon sheath were measured by 3 radiologists. The mean length of the biceps tendon sheath was 47.5mm. The mean distances from the inferior margin of the subscapularis tendon and from the inferior margin of the bicipital groove to the distal extent of the biceps tendon sheath were 24.5mm and 11.9mm, respectively. The relationships among these 3 anatomical measurements and biological confounders of sex and age were investigated while controlling for measurement variability. The anatomical relationships between the biceps tendon sheath and surrounding structures may have implications for needle placement when attempting to inject into the biceps tendon sheath for diagnostic or therapeutic purposes.
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Affiliation(s)
- Nathan Webb
- Department of Radiology, University of Colorado School of Medicine, Aurora, CO
| | - Jonathan Bravman
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO
| | - Alexandria Jensen
- Department of Biostatistics & Informatics, Colorado School of Public Health, Aurora, CO
| | - Jonathan Flug
- Division of Musculoskeletal Radiology, Department of Radiology, University of Colorado School of Medicine, Aurora, CO
| | - Colin Strickland
- Division of Musculoskeletal Radiology, Department of Radiology, University of Colorado School of Medicine, Aurora, CO.
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Saltzman BM, Collins MJ, Leroux T, Arns TA, Griffin JW, Romeo AA, Verma NN, Forsythe B. Arthroscopic Repair of Isolated Subscapularis Tears: A Systematic Review of Technique-Specific Outcomes. Arthroscopy 2017; 33:849-860. [PMID: 28082063 DOI: 10.1016/j.arthro.2016.10.020] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 10/19/2016] [Accepted: 10/20/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE To systematically review the literature to identify all studies reporting outcomes of arthroscopically repaired isolated subscapularis tears, to (1) report outcomes across all repair techniques, (2) compare outcomes by arthroscopic technique, and (3) highlight the frequency and management of associated long head of biceps pathology, and the influence of these concomitant procedures on outcomes following arthroscopic subscapularis repair. METHODS A systematic literature review was conducted using the MEDLINE, Embase, and Scopus databases with the following term: ("isolated repair" AND "arthroscopic subscapularis tear"). Only studies evaluating the techniques and outcomes of isolated subscapularis repair were included. Data were extracted, including patient characteristics, surgical technique, and outcomes. Descriptive analysis was provided for the available literature. RESULTS Eight studies were included in this review. Uniformly, improvements in patient-reported outcome scores were substantial after arthroscopic subscapularis repair. Constant Total scores improved in each individual study from preoperative to postoperative (range, Δ18.8-Δ49.8 points), as did Strength (range, Δ1.3-Δ13.7 points), Pain (range, Δ7.6-Δ8.9 points), Range of Motion (range, Δ7.3-Δ13.3 points), and Activities of Daily Living (range, Δ8.7-Δ10.2 points) subscores. Significant improvements were seen in most individual studies for belly-press (Δ21.6 N or Δ1.9 out of 5) and lift-off strength (Δ24.3 N or Δ1.7-Δ1.9 out of 5), range of motion in forward flexion (29.1°-37.0°), external rotation (10.3°-16.0°), and internal rotation. Complications were relatively infrequent overall, with 5 studies reporting no complications, and the remaining 3 studies with rerupture rates between 4.8% and 11.8%. Studies that used only double-row repair reported fewer complications (0% vs 5%-10%) and better outcome scores than single-row repair, similar to those studies that uniformly performed biceps tenodesis compared with no biceps intervention. CONCLUSIONS This descriptive study highlights that arthroscopic subscapularis repair appears to be a reasonable option for the treatment of isolated tears of the subscapularis to obtain successful functional and patient-reported clinical outcomes. Its findings also pose the question of whether future prospective, comparative studies will find double-row surgical fixation and concomitant biceps tenodesis surgery to be superior to single-row fixation and leaving the biceps alone. LEVEL OF EVIDENCE Level IV, systematic review of Level IV studies.
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Affiliation(s)
- Bryan M Saltzman
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Michael J Collins
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Timothy Leroux
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Thomas A Arns
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Justin W Griffin
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Anthony A Romeo
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Nikhil N Verma
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Brian Forsythe
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A..
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Maher A, Leigh W, Brick M, Young S, Caughey M. Causes of pain and loss of function in rotator cuff disease: analysis of 1383 cases. ANZ J Surg 2017; 87:488-492. [DOI: 10.1111/ans.13870] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Revised: 10/14/2016] [Accepted: 11/06/2016] [Indexed: 01/21/2023]
Affiliation(s)
- Anthony Maher
- Department of Orthopaedics; Wanganui Hospital; Wanganui New Zealand
| | - Warren Leigh
- Department of Orthopaedics; Orthosports North Harbour; Auckland New Zealand
| | - Matt Brick
- Department of Orthopaedics; Orthosports North Harbour; Auckland New Zealand
| | - Simon Young
- Department of Orthopaedics; North Shore Hospital; Auckland New Zealand
| | - Michael Caughey
- Department of Orthopaedics, Middlemore Hospital; Auckland New Zealand
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Ultrasonographic Validation of Anatomical Landmarks for Localization of the Tendon of the Long Head of Biceps Brachii. BIOMED RESEARCH INTERNATIONAL 2017; 2017:1925104. [PMID: 28299316 PMCID: PMC5337311 DOI: 10.1155/2017/1925104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Accepted: 01/19/2017] [Indexed: 11/24/2022]
Abstract
Objectives. To establish anatomical landmarks for biceps tendon groove localization based on intrinsic anatomical relations and to validate the localization with ultrasonographic measurement. Design. Perspective, observational, single-blinded pilot study. Participants. 25 healthy male and female volunteers ages 24–50 years. Methods. We used two anatomical landmarks, the medial epicondyle vertical line related landmark and the coracoid process landmark. The distance from the groove skin mark to the medial epicondyle vertical line and the coracoid process was measured horizontally and was measured at 0° and 45° of shoulder external rotation, respectively. Results. Medial epicondyle vertical lines were 9.3 mm/21.5 mm medial to the groove at 0°/45° of shoulder external rotation, respectively. Correlation coefficients were 0.04/0.10, 0.32/0.42, and 0.26/0.37 for weight, height, and BMI in 0°/45° of shoulder external rotation, respectively. The distance between the coracoid process and the groove was 44.0 mm/62.2 mm in 0°/45° of shoulder external rotation, respectively. Correlation coefficients were 0.36/0.41, 0.36/0.54, and 0.18/0.12 for weight, height, and BMI in 0°/45° of shoulder external rotation, respectively. Conclusions. The medial epicondyle vertical line and the coracoid process landmark are both useful anatomical landmarks to localize the biceps groove. The anatomical landmark based localization is essentially not correlated with subject's weight, height, or BMI.
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Abstract
Lesions of the proximal long head of the biceps tendon (LHB) have been considered as a major cause of shoulder pain and dysfunction. The role of the LHB in causing pain has been a source of controversy for many years, and extensive literature is available discussing anatomy, function, pathology, and most importantly appropriate treatment. Despite this, there is a lack of consensus in the literature regarding the management of biceps-related pathology. Biceps tenotomy and tenodesis are common surgical treatment options when dealing with LHB-related pathology. In this review, a brief discussion on surgical options is provided while focusing on the different options for biceps tenodesis including outcomes and complications.
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Affiliation(s)
- Saad M AlQahtani
- Division of Orthopedic Surgery, Department of Surgery, Queen's University, Kingston General Hospital, Watkins 3, 76 Stuart Street, Kingston, Ontario, Canada, K7L 2V7
- Department of Orthopedic Surgery, University of Dammam, Dammam, Saudi Arabia
| | - Ryan T Bicknell
- Division of Orthopedic Surgery, Department of Surgery, Queen's University, Kingston General Hospital, Watkins 3, 76 Stuart Street, Kingston, Ontario, Canada, K7L 2V7.
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Chernchujit B, Zonthichai N. Comparison of accuracy of anterior and superomedial approaches to shoulder injection: an experimental study. SICOT J 2016; 2:13. [PMID: 27163102 PMCID: PMC4849256 DOI: 10.1051/sicotj/2015044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Introduction: We aimed to compare the accuracy between the standard anterior technique of shoulder injection and the new superomedial technique modified from Neviaser arthroscopic portal placement. Intra-articular placement, especially at the long head of biceps (LHB) tendon, and needle depth were evaluated. Methods: Fifty-eight patients (ages 57 ± 10 years) requiring shoulder arthroscopy in the beach-chair position were recruited. Needle punctures for both techniques were performed by an experienced sports medicine orthopedist. Patients were anesthetized, and the shoulder placed in the neutral position. A single needle was passed through the skin, with only one redirection allowed per trial. The superomedial technique was performed, then the anterior technique. Posterior-portal arthroscopy determined whether needle placement was inside the joint. The percentage of intra-articular needle placements for each technique defined accuracy. When inside the joint, the needle’s precise location was determined and its depth measured. A marginal χ2 test compared results between techniques. Results: The superomedial technique was significantly more accurate than the anterior technique (84% vs. 55%, p < 0.05). For superomedial versus anterior attempts, the LHB tendon was penetrated in 4% vs. 28% of patients, respectively, and the superior labrum in 35% vs. 0% of patients, respectively; the needle depth was 42 ± 7 vs. 32 ± 7 mm, respectively (all p < 0.05). Conclusions: The superomedial technique was more accurate, penetrating the LHB tendon less frequently than the standard anterior technique. A small-diameter needle was needed to minimize superior labral injury. The superomedial technique required a longer needle to access the shoulder joint.
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Affiliation(s)
- Bancha Chernchujit
- Department of Orthopaedic Surgery, Faculty of Medicine, Thammasat University Hospital Klong-Nueng, Klong-Luang, Pathumthani 12120 Thailand
| | - Nutthapon Zonthichai
- Department of Orthopaedic Surgery, Faculty of Medicine, Thammasat University Hospital Klong-Nueng, Klong-Luang, Pathumthani 12120 Thailand
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Volume and Movement Affecting Flow of Injectate Between the Biceps Tendon Sheath and Glenohumeral Joint: A Cadaveric Study. AJR Am J Roentgenol 2016; 206:373-7. [DOI: 10.2214/ajr.15.14733] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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