Disorders of the proximal and distal aspects of the biceps muscle

Outcomes and Patient Satisfaction of Delayed Distal Biceps Repairs without Graft Augmentation: A Systematic Review

BACKGROUND

Distal biceps tendon tears are responsible for 3% to 10% of all biceps ruptures. Treated nonoperatively, these injuries result in poor endurance, loss of supination strength, and loss of flexion strength compared with those treated operatively with repair or reconstruction. When presenting in a chronic fashion, operative management can involve graft reconstruction or primary repair. When there is adequate tendon excursion and quality, primary repair is preferred. The purpose of this systematic review was to investigate the literature regarding outcomes of direct surgical repair of chronic distal biceps tendon ruptures.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed to perform this systematic review and for the presentation of results. A search of the literature was performed on the electronic database Medline, Scopus, and the Cochrane Library. Included studies evaluated subjective and objective outcomes after delayed treatment (≥4 weeks postinjury) for chronic distal biceps tendon ruptures, without use of graft augmentation. Subjective and objective outcome metrics such as functional scores, range of motion, strength, pain level, and return to employment were collected.

RESULTS

Eight studies were reviewed. The studies included 124 patients with chronic distal biceps tendon tears, treated surgically after a mean delay to surgery of 121.8 days. Four studies included comparison of patients with acute and chronic tears, whereas the other 4 studies assessed chronic tears only. The findings of these 4 studies suggest that direct repair of chronic tears is correlated with a mildly higher rate of lateral antebrachial cutaneous nerve (LABCN) injury palsy (10/82 [12.1%] chronic vs. 3/38 [7.9%] acute, p = 0.753); however, this complication was overwhelmingly transient. There were only 3 reported reruptures (3.19%) across 5 studies reporting this complication. Overall, patients who had undergone direct repair of chronic distal biceps tears had good patient satisfaction, outcomes, and range of motion.

CONCLUSION

Direct repair of chronic distal biceps tendon tears without the use of graft reconstruction is associated with acceptable patient satisfaction, range of motion, and functional outcome scores, although transient LABCN palsy rates may be slightly higher. When sufficient residual tendon is present in the setting of chronic distal biceps rupture, direct repair is a viable treatment option. However, the existing literature regarding direct repair of chronic distal biceps repair is limited, and further prospective assessment directly comparing primary repair vs. reconstruction of chronic distal biceps ruptures is warranted.

LEVEL OF EVIDENCE

Level IV. See Instructions for Authors for a complete description of levels of evidence.

Biceps Tenodesis in Patients Age 35 Years and Younger Yields Favorable Clinical Outcomes With Variable Rates of Return to Sport and Complications: A Systematic Review

PURPOSE

To systematically evaluate reported clinical outcomes, return-to-sport (RTS) rates, and complications following biceps tenodesis in patients aged 35 years and younger and compare outcomes between overhead and nonoverhead athletes.

METHODS

A literature search was performed by querying Scopus, EMBASE, and PubMed computerized databases from database inception through August 2022 in accordance with the 2020 Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Studies that evaluated clinical outcomes following biceps tenodesis in patients aged 35 years or younger were included. Study quality was assessed via the Methodological Index for Non-Randomized Studies criteria. Clinical outcomes, RTS rates, and complications were aggregated.

RESULTS

Nine studies from 2011 to 2022 comprising 161 patients (mean age, 25 years; range, 19.7-28.9 years) were included. At an average follow-up of 59 months, postoperative American Shoulder and Elbow Surgeons score ranged from 81.6 to 96 and the mean visual analog scale score ranged from 0 to 2.1. Mean overall RTS rate ranged from 35% to 100% for the entire patient cohort 35% to 86% among overhead athletes, and 46% to 100% among nonoverhead athletes. Among the overhead athletes, 24 were baseball pitchers. 17% to 100% able to return to sport at any level. Complications were reported in 0% to 19% of patients. 0 to 18% of patients underwent revision surgery.

CONCLUSIONS

Biceps tenodesis in patients 35 years of age and younger yields a wide variability in reported RTS rates, excellent clinical outcome scores, and low but variable reported rates of complications, reoperations, and failure.

LEVEL OF EVIDENCE

IV; Systematic Review of Level III and IV studies.

Rotator cuff repair with or without proximal end detachment for long head of the biceps tendon tenodesis

Background

Rotator cuff tears cause pathologies of the long head of the biceps tendon (LHBT). One of the surgical treatments for such a tear is LHBT tenodesis to the humerus. This study aims to compare simultaneous rotator cuff repair and LHBT tenodesis with or without detachment of the proximal end of the LHBT (PELHBT) from its site of adhesion to the glenoid.

Methods

This retrospective study involved patients affected by LHBT pathology with rotator cuff tear. The patients were divided into two groups, with or without PELHBT detachment from the glenoid. Therapeutic outcomes were investigated by evaluation of patient satisfaction, pain based on visual analog scale, shoulder function based on Constant score and simple shoulder test, and biceps muscle strength based on the manual muscle testing grading system before surgery, at 6 months, and at the final visit after surgery.

Results

Groups 1 and 2 comprised 23 and 26 patients, respectively, who showed no significant differences in demographic characteristics (p>0.05). Shoulder function, biceps muscle strength, pain, and satisfaction rate improved over time (p<0.05) but were not significantly different between the two groups (p>0.05). No post-surgical complication was found in either group.

Conclusions

There was no difference in final outcomes of tenodesis with or without detachment of the PELHBT from the supraglenoid tubercle. Such tendon detachment is not necessary.

Tenodesis yields better functional results than tenotomy in long head of the biceps tendon operations-a systematic review and meta-analysis

Background

Pathology of the long head of the biceps tendon (LHBT) is a common disorder affecting muscle function and causing considerable pain for the patient. The literature on the two surgical treatment methods (tenotomy and tenodesis) is controversial; therefore, our aim was to compare the results of these interventions.

Methods

We performed a meta-analysis using the following strategy: (P) patients with LHBT pathology, (I) tenodesis, (C) tenotomy, (O) elbow flexion and forearm supination strength, pain assessed on the ten-point Visual Analog Scale (VAS), bicipital cramping pain, Constant, ASES, and SST score, Popeye deformity, and operative time. We included only randomized clinical trials. We searched five databases. During statistical analysis, odds ratios (OR) and weighted mean differences (WMD) were calculated for dichotomous and continuous outcomes, respectively, using the Bayesian method with random effect model.

Results

We included 11 studies in the systematic review, nine of these were eligible for the meta-analysis, containing data about 572 patients (279 in the tenodesis, 293 in the tenotomy group). Our analysis concluded that tenodesis is more beneficial considering 12-month elbow flexion strength (WMD: 3.67 kg; p = 0.006), 12-month forearm supination strength (WMD: 0.36 kg; p = 0.012), and 24-month Popeye deformity (OR: 0.19; p < 0.001), whereas tenotomy was associated with decreased 3-month pain scores on VAS (WMD: 0.99; p < 0.001). We did not find significant difference among the other outcomes.

Conclusion

Tenodesis yields better results in terms of biceps function and is non-inferior regarding long-term pain, while tenotomy is associated with earlier pain relief.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00264-022-05338-9.

Arthroscopic Evaluation of the Long Head of the Biceps Tendon: Traditional Versus Allis Clamp Techniques

Using a probe to retract the long head of the biceps tendon (LHBT) into the joint is common practice for visualizing the extra-articular portions during arthroscopy. However, extra-articular lesions may be missed in up to half of cases. Greater excursion of the LHBT may be achieved with an Allis clamp grasper. Our goal was to quantify portions of the extra-articular LHBT that could be visualized during shoulder arthroscopy with the Allis clamp and probe techniques. Shoulder arthroscopy was performed on 8 forequarter cadaveric specimens in the simulated beach chair position, and the most distal extent of the intra-articular LHBT was marked. The tendon was pulled into the joint with both techniques, and the additional exposed tendon portion was marked. An open approach was performed, and the locations of the 3 marks were assessed relative to total tendon length. Mean LHBT total length was 96.25 mm. Diagnostic arthroscopy allowed visualization of a mean of 21.75 mm of the intra-articular tendon (22.6% of the total length). The traditional probe technique provided visualization of 31.13 mm (32.8%). The Allis clamp technique provided visualization of 49.38 mm (52%) and increased visualization of the LHBT by 58.6% (P<.0001). A mean of 46.87 mm (48%) of the LHBT remained unvisualized. The Allis clamp technique maximizes arthroscopic visualization of extra-articular LHBT. The distal 48% eludes evaluation, but can be visualized when combined with an open technique without the need to divide the transverse humeral ligament. The Allis clamp technique facilitates additional identification of LHBT pathology that could otherwise remain hidden during shoulder arthroscopy. Because the LHBT is a major source of pain in the shoulder, this technique may improve outcomes of shoulder arthroscopy and reduce the need for revision because of remnant anterior shoulder pain. [Orthopedics. 2022;45(1):38-42.].

Efficacy of management of associated dysfunctions on rotator cuff and long head of the biceps: systematic review

Background

The important functional role the rotator cuff (RC) and biceps play in the shoulder, the close anatomical relationship between them and the high incidence of injuries require an appropriate multidisciplinary therapeutic approach after a rigorous assessment. The objective is to identify and analyze surgical interventions, whether or not followed by a postsurgical one, of associated dysfunctions on the RC and long head of the biceps (LHB) and their effectiveness in improving shoulder functionality.

Methods

A systematic review based on PRISMA protocol was conducted using PubMed, Web of Science, PEDro, Scopus, CINAHL, and Dialnet until 22 April 2021. The main inclusion criteria were as follows: randomized clinical trials including subjects diagnosed with RC and LHB lesions who had surgical and/not post-surgical treatments. The methodological quality of trials was evaluated by the PEDro scale. Data were shown in 3 pre-established tables: (1)sample data, diagnostic methods, dysfunctions and injury frequency, interventions, outcome measures and results; (2)significance and effectiveness of interventions; and (3)comparison of the effectiveness of interventions.

Results

Eleven studies were selected. The methodological quality of ten of them was assessed as good and one excellent (PEDro scale). All articles had surgical treatments and ten had postoperative management. All trials used arthroscopy and two open surgery too. Single-row, double-row and transosseous repair were used for RC lesions, while SLAP repair, tenotomy, and tenodesis were applied to LHB injuries. Measured parameters were functionality, pain, Popeye’s sign, strength, range of motion, satisfaction degree, biceps cramping, and quality of life. All approaches in general, surgical plus postsurgical, were always effective to the parameters measured in each study. Seven trials compared tenotomy and tenodesis: four of them obtained statistically significant differences in favor of tenodesis in Popeye’s sign, cramping, satisfaction degree, and/or forearm supination strength; and one, in favor of tenotomy in cramping. All studies measured functionality using functional assessment scales. The most widely used was the Constant Score.

Conclusions

Surgical plus post-surgical interventions in associated dysfunctions on RC and LHB were effective. Tenodesis obtained better results than tenotomy in Popeye’s sign, satisfaction, and forearm supination strength. However, there was no difference regarding biceps cramping.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-021-02621-0.

Progression of long head of the biceps brachii tendon abnormality on magnetic resonance imaging after rotator cuff repair

OBJECTIVES

To correlate the deterioration of preserved long head of biceps tendon (LHB) after rotator cuff repair with preoperative and postoperative MRI factors.

METHODS

Total of 209 shoulder joints (F:M = 145:64; mean age 57.4 years) which underwent rotator cuff repair and at least two postoperative MRI scans over 10 months after surgery were included. LHB integrity was graded with a five point severity scale. LHB deterioration was defined by increased composite score of integrity and extent score between the preoperative and second postoperative MRI. For preoperative and postoperative MRI factors, size and location of superior cuff -supraspinatus and infraspinatus- and subscapularis tears, fatty degeneration of rotator cuff, preoperative LHB status, subluxation of LHB, superior labral tear, acromion type, repaired rotator cuff status, postoperative capsulitis and acromioplasty state were assessed. Logistic regression was used to evaluate the association between LHB deterioration and aforementioned factors. Same analysis was conducted for 62 shoulder joints with a long-term follow-up MRI.

RESULTS

Of the 209 shoulders, 49.3% (n = 103) showed LHB deterioration on short-term follow-up MRI. In long-term follow-up subgroup, 32 LHBs were further deteriorated. In multivariate analysis, fatty degeneration of superior cuff showed significant association with LHB deterioration in both short-term (p = .04, p = .007) and long-term subgroups (p = .004, p = .005) among preoperative and postoperative factors, respectively.

CONCLUSIONS

Degree of fatty degeneration in superior cuff is associated with LHB deterioration on postoperative MRI.

ADVANCES IN KNOWLEDGE

Our results support that tenotomy or tenodesis of LHB should be considered during rotator cuff repair, especially in patients with advanced fatty degeneration of rotator cuff.

The Flexion Initiation Test and an Evidence-Based Diagnostic Algorithm for Distal Biceps Tendon Tears

Purpose

The purpose of this study was (1) to assess the flexion initiation test’s (FIT) ability to detect distal biceps tendon tears (DBTT) in a cohort of consecutive patients presenting with elbow pain and (2) to generate a reliable evidence-based diagnostic algorithm using a combination of both the FIT and hook tests.

Methods

We performed a retrospective review of 125 consecutive patients who presented with elbow pain, all of which had the FIT and hook test performed prior to imaging/further intervention. The integrity of the tendon was determined during surgery or by magnetic resonance imaging. Sensitivity, specificity, positive predictive value, and negative predictive value were determined for the FIT and hook test.

Results

Our evidence-based diagnostic algorithm showed that when both test results are in agreement, there is a 100% diagnostic accuracy for detecting what prior authors have termed surgically indicated tears (complete ruptures and high-grade partial tears) and biceps pathology that can be treated with nonoperative management. The FIT demonstrated 100% sensitivity for surgically indicated tears. The hook test demonstrated 100% sensitivity for complete ruptures, but 18% sensitivity for diagnosing partial tears.

Conclusions

The FIT, which is aimed at improving diagnostic acuity of high-grade partial thickness tears, demonstrated a 93% sensitivity and 96% specificity overall and a 100% sensitivity for complete ruptures and high-grade partial tears. The evidence-based diagnostic algorithm using the combination of the FIT and hook test demonstrates high accuracy for the diagnosis of both complete and high-grade partial DBTTs. The methodology may help to prevent diagnosis delays, improve patient education, and preserve the option for timely primary surgical repair in the treatment of DBTTs.

Level of Evidence

Level IV, diagnostic.

Missed Bilateral Anterior Shoulder Dislocation With Bilateral Coracoid Fracture and Unilateral Long Head of Biceps Rupture

Missed or chronic bilateral anterior shoulder dislocation is a rare presentation, usually secondary to epileptic attack. We present herein an exceptional case of this injury pattern, associated with bilateral displaced fracture of the coracoid process, and unilateral rupture of the long head of biceps. Treatment consisted of open reduction through osteotomy of the lesser tuberosity, with additional stabilization of the glenohumeral joint, using the Latarjet procedure by transposition of the coracoid fragment with its attached conjoint tendon to the antero-inferior glenoid rim. Rupture of the long head of the biceps required tenodesis. Temporary glenohumeral pin transfixation was performed for residual instability at the end of the procedure. Patients with postictal shoulder pain, discomfort, or disability should be investigated with adequate radiographs, in addition to CT scan or MRI when needed. Early diagnosis allows for safe closed reduction, and helps avoid late and more complex surgical treatment required for missed or chronic dislocations.

Chronic distal biceps avulsion treated with suture button

BACKGROUND

Distal biceps tendon avulsions account for 3%-10% of all biceps ruptures. Treated nonoperatively, these injuries lead to a loss of endurance, supination strength, and flexion strength compared with operative repair or reconstruction. Operative management of chronic injury has classically been with graft tissue to augment the contracted muscle. We present our results for chronic distal biceps avulsions secured with suture button through a single transverse incision in high flexion without the need for allograft augmentation.

MATERIALS AND METHODS

This was a retrospective review of 20 patients with 21 injuries who underwent primary surgical repair of chronic distal biceps tendon avulsions at an average of 10 weeks (range 4-42 weeks). All patients were treated with a single transverse incision with a suture button armed with nonabsorbable no. 2 core sutures. Postoperatively patients were found to have 50°-90° flexion contracture. All patients were placed in a simple sling postoperatively with gentle extension to gravity as tolerated immediately and no formal physical therapy. Patients were surveyed regarding pre- and postoperative American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, visual analog scale (VAS) score, Mayo Elbow Performance Score (MEPS), Oxford Elbow Score (OES), and overall satisfaction. Range of motion (ROM), flexion, and supination strength compared to the contralateral uninjured extremity were evaluated at final follow-up.

RESULTS

Mean clinical follow-up was 26 months. All patients regained full ROM and 5/5 flexion and supination strength at final follow-up. MEPSs were 100 for all responding patients compared with an average 47.5 preoperatively (P < .0001). The mean postoperative ASES score was 97.2 compared with 41.9 preoperatively (P < .0001). Mean OESs pre- and postoperatively were 24.2 and 48, respectively (P < .0001). The mean VAS score was 4.4 preoperatively and was reported as 0 by all patients at final follow-up (P < .0001). Two patients had transient sensory radial nerve neuropathy, and 1 patient has persistent palsy. No synostoses occurred. Four patients reported supination fatigue postoperatively compared with the uninjured extremity.

CONCLUSION

Given these results, we feel that chronic distal biceps tendon ruptures can be repaired successfully with a single incision using suture button technique without the use of a graft. Though the flexion contracture is significant postoperatively, all patients regained full ROM and had excellent postoperative functional outcome scores.

Patients older than 55 years prefer biceps tenodesis over tenotomy to the same degree as young patients

BACKGROUND

55 years of age used to be the cutoff point when deciding between biceps tenotomy and tenodesis for treating biceps tendon pathologies.

METHODS

Patients aged ≥18 years who had tendonitis in the long head of the biceps and were admitted for arthroscopic surgery were included. A questionnaire with a series of questions assessing patients' current symptoms, their concerns about their outcomes, and personal demographic information was introduced to the participants on the day before the surgery. The patients' preference toward tenotomy and tenodesis was assessed, and χ2 tests and logistic regressions were used to test the association with the categorical and ordinal variables, respectively.

RESULTS

A total of 135 patients enrolled in the study, with 83 males and 52 females, the mean age of which was 56 years (range, 18-75 years). Of all patients, 86 (63.7%) preferred biceps tenodesis as opposed to tenotomy; meanwhile, there was no difference in preference toward tenodesis in each age- and gender-subgroup (range, 55.1% to 71.4%). The different subgroups had specific factors that were predictive of choosing either a tenotomy or tenodesis. In most subgroups, concerns about postoperative arm appearance and the so-called "Popeye" deformity due to tenotomy were factors predictive of choosing biceps tenodesis, whereas concern about longer rehabilitation due to tenodesis was the factor predictive of choosing biceps tenotomy.

CONCLUSIONS

Biceps tenodesis is a more preferable choice for patients with biceps tendinopathies in all age and gender subgroups. Patients' concerns on postoperative arm appearance, "Popeye" deformity due to tenotomy, and longer rehabilitation due to tenodesis are the most important predictive factors.

Management of Failed Proximal Biceps Surgery: Clinical Outcomes After Revision to Subpectoral Biceps Tenodesis

BACKGROUND

The preferred surgical technique to manage biceps-superior labral pathology is often debated, and rates of revision and persistence of pain vary widely according to surgical technique and patient characteristics.

PURPOSE

To evaluate the clinical and functional outcomes of patients undergoing revision subpectoral tenodesis after failed primary tenodesis or tenotomy of the long head of the biceps.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

All patients undergoing revision biceps management by the senior surgeon between 2006 and 2016 and with a minimum 24-month follow-up were retrospectively identified. Patients being treated with concomitant rotator cuff repair or capsular release were excluded. Patient characteristic variables were recorded. Patient-reported outcomes including the functional score, Single Assessment Numeric Evaluation (SANE), visual analog scale (VAS), Simple Shoulder Test (SST), and American Shoulder and Elbow Surgeons were obtained, and range of motion, strength, and complications were quantified.

RESULTS

In total, 25 patients with revision biceps tenodesis were identified at a mean follow-up of 76.5 ± 31.5 months. The average age was 44.4 ± 14.3 years, and the surgical indications included failure of index suprapectoral biceps tenodesis (56%), subpectoral biceps tenodesis (36%), and patient dissatisfaction after tenotomy (8%). There was a significant improvement in the VAS score (P < .001), SANE (P = .001), SST (P = .035), functional score (P < .001), and forward elevation (P = .028), whereas postoperative strength (P = .440), abduction (P = .100), and external rotation (P = .745) improvement failed to achieve statistical significance after revision surgery. There was no difference in postoperative outcome measures between modes of failures, concomitant procedures, and sex. Twenty-two (88%) patients reported high satisfaction and stated they would have this revision surgery again. The overall complication rate was 48%, with half of these reporting pain of >3 on a scale of 10 and 4% of patients requiring additional surgeries.

CONCLUSION

The current study demonstrates high patient satisfaction (88%) and significant improvement in functional outcomes with revision biceps tenodesis, a mini-open subpectoral technique, after previous failed tenodesis or tenotomy. Although this may be an effective strategy to address failed prior biceps surgery, the potential complication of persistent pain must be emphasized. Patients should be counseled on the high complication rate (48%), with persistent pain being the most common complaint.

Labral Repair Versus Biceps Tenodesis for Primary Surgical Management of Type II Superior Labrum Anterior to Posterior Tears: A Systematic Review

PURPOSE

To examine the outcomes of SLAP repair versus biceps tenodesis (BT) for the index treatment of isolated type II SLAP tears.

METHODS

A search of PubMed, MEDLINE, and EMBASE was performed in April 2018 for English-language studies that presented outcomes data on patients with isolated type II SLAP tears treated with either SLAP repair or BT at the primary surgical time point.

RESULTS

Twenty-three studies (i.e., 2 randomized control trials, 7 retrospective cohort, 3 prospective cohort, 4 case-control, and 7 case series) were included. Isolated type II SLAP tears were treated via SLAP repair in 781 patients with a mean age of 35 years (range, 22-58 years) and a mean postoperative follow-up of 35 months (range, 3-63 months). BT was performed in 100 patients with a mean age of 44 years (range, 18-64 years) and a mean postoperative follow-up of 32 months (range, 24-75 months). Similar postoperative scores were noted in both the SLAP repair and BT groups for American Shoulder and Elbow Surgeons, Constant, University of California, Los Angeles, and visual analog scale pain scores. The rate of return to sports was 20% to 95% for SLAP repair and 73% to 100% for BT. Reoperation rates for SLAP repair and BT were 2.9% to 40% and 0% to 15.3%, respectively.

CONCLUSIONS

This study suggests that SLAP repair and BT are both acceptable as index treatment for isolated type II SLAP tears. SLAP repair remains the most commonly performed index procedure; however, BT appears equally efficacious and may represent an attractive alternative.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I through IV studies.

Bye Bye Biceps: Case Report Describing Presentation, Physical Examination, Diagnostic Workup, and Treatment of Acute Distal Biceps Brachii Tendon Rupture

BACKGROUND

Rupture of the distal biceps tendon is seen in both the emergency and primary care settings. It most commonly occurs after excessive tension exerted on a flexed forearm. Knowledge of the anatomy, pathophysiology, historical and physical examination findings, as well as the workup, diagnosis, and treatment of distal biceps tendon rupture are essential in achieving good outcomes, as delays in treatment can make surgical repair more challenging and less efficacious.

CASE REPORT

A healthy 38-year-old male presented to his primary care physician complaining of right elbow pain that started while lifting an all-terrain vehicle into a truck. On physical examination, the patient had obvious deformity of the distal upper arm, as well as a positive squeeze test. Magnetic resonance imaging confirmed the presence of complete rupture of the distal biceps brachii tendon and the patient was referred to orthopedic surgery for evaluation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Prompt diagnosis and referral to orthopedic surgery optimizes outcomes and minimizes complications after distal biceps brachii tendon rupture. Oftentimes, gross examination shows obvious deformity of the distal upper arm, but when swelling, mobility limitations, or patient anatomy hinder this physical examination finding, the diagnosis can be missed. Knowledgeable emergency physicians can perform a physical examination and other diagnostic tests that can confirm or rule out a diagnosis in order to achieve the best outcomes for patients.

Reconstruction of the distal biceps tendon using semitendinosus grafting: Description of the technique

Distal ruptures of the biceps are rare when compared to proximal ruptures, with a different epidemiology and mechanism of trauma. There is no exact pathophysiology, though the hypovascular distal insertion and the mechanical impact during movement should be considered important factors. The surgical treatment of chronic cases presents worse prognosis due to muscle shortening with tendon retraction, making anatomical repair of the injury difficult, requiring the use of grafts for its reconstruction. This is a prospective study involving four patients with chronic distal biceps injury. The tendons were reconstructed with an autologous graft from the semitendinosus tendon from the ipsilateral knee and secured to the radial tuberositywith the help of two anchors. The surgical technique proved to be a simple and viable procedure for the reconstruction of chronic ruptures of the distal biceps.

Radiologic and Histologic Evaluation of Proximal Bicep Pathology in Patients With Chronic Biceps Tendinopathy Undergoing Open Subpectoral Biceps Tenodesis

PURPOSE

To correlate preoperative magnetic resonance imaging (MRI) and intraoperative anatomic findings within the proximal long head biceps tendon to histologic evaluation of 3 separate zones of the tendon in patients with chronic biceps tendinopathy.

METHODS

Sixteen patients with chronic biceps tendinopathy were treated with open subpectoral biceps tenodesis. Preoperative MRI tendon grading was as follows: normal tendon, increased signal, tendon splitting, incomplete/complete tear. The removed portion of the biceps tendon was split into 3 segments: zone 1, 0-3.5 cm from the labral insertion; zone 2, 3.5-6.5 cm; and zone 3, 6.5-9 cm, and was histologically evaluated using the Bonar score. Tenosynovium adjacent to the tendon was assessed histologically using the Osteoarthritis Research Society International score. CD31, CD3, and CD79a immunohistochemistries were conducted to determine vascularization, T-cell infiltrates, and B-cell infiltrates, respectively. Analysis of variance and Pearson correlations were performed for statistical analysis.

RESULTS

Preoperative MRI showed no significant differences in tendon appearance between zones 1-3. Intraoperative findings included nonspecific degenerative SLAP tears or mild/moderate biceps tenosynovitis in all cases. Significantly (P < .001) higher Bonar scores were noted for tendon in zones 1 (7.9 ± 1.8) and 2 (7.3 ± 1.5) compared with zone 3 (5.0 ± 1.1). Cell morphology scores in zone 1 (1.9 ± 0.4) and zone 2 (1.5 ± 0.6) were significantly higher than that in zone 3 (0.8 ± 0.3) (P < .05). Inflammatory tenosynovium showed weak correlation with tendon changes in zone 1 (r = 0.08), zone 2 (r = 0.03), or zone 3 (r = 0.1).

CONCLUSIONS

In patients with chronic long head biceps tendinopathy who underwent open subpectoral tenodesis, MRI and intraoperative assessment did not show significant structural abnormalities within the tendon despite significant histopathologic changes. Severity of tendon histopathology was more pronounced in the proximal and mid-portions of the tendon.

CLINICAL RELEVANCE

Proximal versus distal biceps tenodesis is a subject of frequent debate. This study contributes to the ongoing evaluation of the characteristics of the proximal biceps in this type of pathologic condition.

Comparison of Bone Tunnel and Cortical Surface Tendon-to-Bone Healing in a Rabbit Model of Biceps Tenodesis

BACKGROUND

Many orthopaedic surgical procedures involve reattachment of a single tendon to bone. Whether tendon-to-bone healing is better facilitated by tendon fixation within a bone tunnel or on a cortical surface is unknown. The purpose of this study was to evaluate tendon-healing within a bone tunnel compared with that on the cortical surface in a rabbit model of biceps tenodesis.

METHODS

Thirty-two rabbits (24 weeks of age) underwent unilateral proximal biceps tenodesis with tendon fixation within a bone tunnel (BT group) or on the cortical surface (SA [surface attachment] group). Postoperatively, rabbits were allowed free-cage activity without immobilization. All rabbits were killed 8 weeks after surgery. Healing was assessed by biomechanical testing, microcomputed tomography (micro-CT), and histomorphometric analysis.

RESULTS

Biomechanical testing demonstrated no significant difference between the groups in mean failure loads (BT: 56.8 ± 28.8 N, SA: 55.8 ± 14.9 N; p = 0.92) or stiffness (BT: 26.3 ± 16.6 N/mm, SA: 32.3 ± 9.6 N/mm; p = 0.34). Micro-CT analysis demonstrated no significant difference between the groups in mean volume of newly formed bone (BT: 69.3 ± 13.9 mm, SA: 65.5 ± 21.9 mm; p = 0.70) or tissue mineral density of newly formed bone (BT: 721.4 ± 10.9 mg/cm, SA: 698.6 ± 26.2 mg/cm; p = 0.07). On average, newly formed bone within the tunnel represented only 5% of the total new bone formed in the BT specimens. Histological analysis demonstrated tendon-bone interdigitation and early fibrocartilaginous zone formation on the outer cortical surface in both groups. In contrast, minimal tendon-bone bonding was observed within the tunnel in the BT specimens.

CONCLUSIONS

Tendon fixation in a bone tunnel and on the cortical surface resulted in similar healing profiles. For tendons placed within a bone tunnel, intratunnel healing was minimal compared with the healing outside the tunnel on the cortical surface.

CLINICAL RELEVANCE

The creation of large bone tunnels, which can lead to stress risers and increase the risk of fracture, may not be necessary for biceps tenodesis procedures.

Management of Biceps Tendon Pathology: From the Glenoid to the Radial Tuberosity

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.

Popeye sign: Tenodesis vs. self-locking "T" tenotomy of the long head of the biceps

INTRODUCTION

Treatment of long head of the biceps lesions is controversial. A new technique of self-locking "T" tenotomy was developed in our department in 2013.

HYPOTHESIS

The main objective of the present study was to assess onset of Popeye sign after "T" tenotomy, with comparison to long head of the biceps tenodesis.

MATERIAL AND METHODS

A continuous retrospective study included 180 patients with long head of the biceps lesion, either isolated or associated with rotator cuff tear.

RESULTS

130 underwent "T" tenotomy (group A), and 50 tenodesis (group B). Mean age was 57.9 years (range, 23-88 years) in group A and 50.8 years (range, 20-66 years) in group B. At last follow-up, 27.7% of patients in group A and 24% in group B showed Popeye sign (P=0.616), after equivalence test and adjustment on age and occupational activity. Bicipital groove pain was more frequent in the tenodesis group (44% versus 25.4%; P=0.025).

DISCUSSION

Self-locking "T" tenotomy did not significantly differ from tenodesis in onset of Popeye sign or clinical results, and showed better postoperative course.

LEVEL OF EVIDENCE

IV, retrospective study.

Physical examination tests and imaging studies based on arthroscopic assessment of the long head of biceps tendon are invalid

PURPOSE

The aim of this study was to evaluate whether glenohumeral arthroscopy is an appropriate gold standard for the diagnosis of long head of biceps (LHB) tendon pathology. The objectives were to evaluate whether the length of tendon that can be seen at arthroscopy allows visualisation of areas of predilection of pathology and also to determine the rates of missed diagnoses at arthroscopy when compared to an open approach.

METHODS

A systematic review of cadaveric and clinical studies was performed. The search strategy was applied to MEDLINE, PubMed and Google Scholar databases. All relevant articles were included. Critical appraisal of clinical studies was performed using a validated quality assessment scale.

RESULTS

Five articles were identified for inclusion in the review. This included both clinical and cadaveric studies. The overall population comprised 18 cadaveric specimens and 575 patients. Out of the five included studies, three reported the length of LHB tendon visualised during arthroscopy and four reported the rate of missed LHB diagnosis. Cadaveric studies showed that the use of a hook probe allowed arthroscopic visualisation of between 34 and 48 % of the overall length of the LHB. In the clinical series, the rate of missed diagnoses at arthroscopy when compared to open exploration ranged between 33 and 49 %.

CONCLUSIONS

Arthroscopy allows visualisation of only a small part of the extra-articular LHB tendon. This leads to a high rate of missed pathology in the distal part of the tendon. Published figures for sensitivities and specificities of common physical examination and imaging tests for LHB pathology that are based on arthroscopy as the gold standard are therefore invalid. In clinical practice, it is important to note that a "negative" arthroscopic assessment does not exclude a lesion of the LHB tendon as this technique does not allow visualisation of common sites of distal pathology.

LEVEL OF EVIDENCE

IV.

Radial Extracorporeal Shock Wave Therapy Is Effective and Safe in Chronic Distal Biceps Tendinopathy

OBJECTIVE

To assess the efficacy and safety of radial extracorporeal shock wave therapy (rESWT) for chronic distal biceps tendinopathy (cDBT).

DESIGN

Case-control study (level of evidence, 3).

SETTING

SUN Orthopaedics and Sports Medicine.

PATIENTS

Patients with a diagnosis of cDBT were recruited between January 2010 and February 2015.

INTERVENTIONS

Patients received a single session of rESWT (2000 shock waves with energy flux density of 0.18 mJ/mm) or other forms of nonoperative therapy.

MAIN OUTCOME MEASURES

Patients completed the visual analog scale (VAS), the modified QuickDASH (MQD) score, and the Roles and Maudsley (RM) score over a 12-month period.

RESULTS

Forty-eight patients completed the final review at 12 months and were included in the study. Subjects ranged in age from 30 to 64 years. Mean pretreatment VAS scores for the rESWT and control groups were 8.3 and 8.5, respectively. Three and 12 months after inclusion in the study, the mean VAS scores for the rESWT and control groups were 3.4 and 5.6 (P < 0.001) and 2.7 and 4.7 (P < 0.001), respectively. Twelve-month follow-up MQD-Sports and MQD-Work scores for the rESWT and control groups were 3.7 and 1.7 (P < 0.001) and 3.8 and 1.8 (P < 0.001), respectively. Differences in mean RM scores were statistically significant between groups at 3 months after the treatment. There were no significant complications.

CONCLUSIONS

Overall, rESWT is an effective and safe treatment for cDBT.

CLINICAL RELEVANCE

Radial ESWT as a novel, effective, and safe treatment for cDBT.

Subpectoral Biceps Tenodesis for Tenosynovitis of the Long Head of the Biceps in Active Patients Younger Than 45 Years Old

PURPOSE

The objective of this study was to assess the outcomes after subpectoral biceps tenodesis (BT) for long head of the biceps (LHB) tenosynovitis in active patients <45 years old.

METHODS

This was an Institutional Review Board-approved, retrospective outcomes study with prospectively collected data. Patients treated with subpectoral BT were included if they met the following criteria: age <45 years, anterior shoulder pain with arthroscopically confirmed LHB tenosynovitis, no concomitant procedures other than debridement and decompression procedures, and minimum 2 years out from surgery. Patients were excluded from analysis if they refused participation. The American Shoulder and Elbow Surgeons (ASES), Short Form-12, Quick Disabilities of the Arm, Shoulder and Hand, Single Assessment Numeric Evaluation, and pain scores as well as sports participation preoperatively and at a minimum of 2 years postoperatively were obtained. Pre- and postoperative scores were compared using paired samples t-test and Wilcoxon signed-rank test.

RESULTS

Thirty patients met the inclusion criteria. Two of these patients refused to participate in follow-up and were excluded from analysis. Of the remaining 28 patients (17 male, 11 female; 37.0 ± 8.0 years), minimum 2-year outcomes were available for 24 (13 males, 11 females: 37.7 ± 8.2 years; 85.7%). Mean follow-up was 3.1 years (range, 2.0 to 7.3 years). There were significant improvements in all outcome measures including ASES score (P < .001), with a postoperative mean of 95.8 ± 7.8, visual analog scale "pain today" (P < .001), and pain affecting activities of daily living (P < .001). Seventeen of 20 (85%) patients who answered the question about postoperative sport participation were able to return to sport. Mean patient satisfaction was 9.2/10 (standard deviation, +1.7). There were no postoperative complications such as Popeye deformity or cramping. There were no clinical failures.

CONCLUSIONS

Subpectoral BT is an excellent treatment option for active patients <45 years old with LHB tenosynovitis and chronic anterior shoulder pain, resulting in decreased pain, improved function, high satisfaction, and improved quality of life.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Biceps Disorder Rehabilitation for the Athlete: A Continuum of Moderate- to High-Load Exercises

BACKGROUND

Progressive biceps loading is recommended in the nonoperative and operative rehabilitation of biceps-related disorders. Previous researchers have proposed a continuum of exercises with low to moderate biceps loads to be used in the early and intermediate phases of rehabilitation. A progression of exercises with moderate to high biceps loads to be used in the more advanced phases of rehabilitation is lacking.

PURPOSE

To describe a progression of exercises with progressive moderate to high loads on the biceps brachii (BB) based on electromyographic (EMG) analysis.

STUDY DESIGN

Controlled laboratory study.

METHODS

The EMG activity of BB and triceps brachii; upper trapezius, middle trapezius, and lower trapezius; and serratus anterior was determined with surface electromyography in 30 asymptomatic participants during 11 exercises.

RESULTS

Of the 11 exercises, 4 (arm shake with an Xco-trainer, lateral pull-down in pronation, chest shake with an Xco-trainer, lateral pull-down in supination) showed low (<20% maximal voluntary isometric contraction [MVIC]), 5 (pull-up in pronation with Redcord, air punch, forward flexion in supination, pull-up in supination with Redcord, inclined biceps curl) showed moderate (between 20%-50% MVIC), and 2 (throwing forward flexion, reverse punch) showed high (>50% MVIC) EMG activity in the BB. These exercises were ranked with an increasing level of activity in the BB.

CONCLUSION

The continuum of exercises with moderate to high biceps activity may be applied in the more advanced phases of treatment for biceps disorders. In addition, biceps muscle activity may be targeted by (1) sagittal plane elevation; (2) elbow flexion with supination, without upper arm support; (3) biceps contraction from an elongated position; or (4) high-velocity, explosive exercises.

CLINICAL RELEVANCE

These findings may assist clinicians to select appropriate exercises to be used in the more advanced phases of nonoperative or postoperative rehabilitation of overhead athletes with biceps-related injuries.

Augmenting the osseointegration of endoprostheses using laser-sintered porous collars: an in vivo study

AIMS

Massive endoprostheses rely on extra-cortical bone bridging (ECBB) to enhance fixation. The aim of this study was to investigate the role of selective laser sintered (SLS) porous collars in augmenting the osseointegration of these prostheses.

MATERIALS AND METHODS

The two novel designs of porous SLS collars, one with small pores (Ø700 μm, SP) and one with large pores (Ø1500 μm, LP), were compared in an ovine tibial diaphyseal model. Osseointegration of these collars was compared with that of a clinically used solid, grooved design (G). At six months post-operatively, the ovine tibias were retrieved and underwent radiological and histological analysis.

RESULTS

Porous collars provided a significantly greater surface (p < 0.001) for the ingrowth of bone than the standard grooved design. Significantly greater extracortical pedicle formation was seen radiologically around the grooved design (length p = 0.002, thickness p < 0.001, surface area p = 0.002) than around the porous collars. However, the ingrowth of bone occurred from the transection site into the porous structure of both types of collar. A fivefold increase in integration was seen with the SP and a threefold increase in the LP design when compared with G (p < 0.001).

CONCLUSION

SLS porous collars allow the direct ingrowth of more bone and are better than current designs which rely on surface ongrowth and ECBB. Cite this article: Bone Joint J 2017;99-B:276-82.

Patients Have Strong Preferences and Perceptions for Biceps Tenotomy Versus Tenodesis

PURPOSE

To evaluate what factors are important in the patients' preference and their perception of a successful surgical outcome.

METHODS

A biceps-specific questionnaire was developed using a series of questions assessing current symptoms, previous knowledge of biceps tendon surgery, surgical outcome priorities, and patient demographics and administered to 100 patients with proximal biceps pathology after approval by the Institutional Review Board. The patients were asked which surgery they would prefer. A set of χ² tests were used to test the association between categorical variables. All tests were 2-sided and considered significant at P < .05.

RESULTS

A total of 100 patients enrolled in the study, with 49 female and 51 male patients at an average age of 49 years (range, 19 to 79 years). Of the 100 patients, 64 (64%) chose to have biceps tenodesis. Factors predictive of choosing a biceps tenodesis included female sex, and concern of cosmetic deformity and residual postoperative pain with a tenotomy (P < .05). Factors predictive of choosing a tenotomy included male sex, high level of current biciptal groove pain, and concerns regarding the use of additional hardware and longer recovery with a tenodesis (P < .05). Age, body mass index, occupation, income level, and concerns regarding postoperative strength and muscle cramping were not found to have a significant predictive effect toward either procedure.

CONCLUSIONS

Patient age should not be used as the sole criterion when deciding between biceps tenotomy and tenodesis. Our results can be consolidated to 5 predictive, reliable questions that will assist orthopaedic surgeons in making individualized patient-specific decisions regarding proximal biceps tendon surgery by emphasizing what factors are most important to patients for a successful surgical outcome.

Surgical indications for long head biceps tenodesis: a systematic review

PURPOSE

Tenodesis as a treatment for a symptomatic long head of biceps (LHB) tendon is becoming more prevalent and new techniques exist which are purported to make the procedure faster and more effective. The determination of appropriate surgical indications for the procedure will facilitate proper analysis and comparisons of the varied techniques. This review analyses the reported indications in the literature in an attempt to guide future research and treatment.

METHODS

The EMBASE and MEDLINE databases were searched to identify surgical studies that report indications for LHB tenodesis. After title, abstract searches, and full-text reviews, 39 studies were included. Study information was extracted including author, publication date, patient numbers, patient age, follow-up period, procedure performed, surgical indications, and study design.

RESULTS

Although indications were variable and often non-descriptive, of the 39 included studies, the most common indications for LHB tenodesis were partial tearing (51 %), instability (49 %), or tenosynovitis (44 %), SLAP tear (28 %), and positive clinical exam for LHB pain (26 %). Most studies were of low quality of evidence, such as case series (33.0 %) and retrospective studies (43.5 %), and were of low-to-moderate methodological quality.

CONCLUSION

Although indications used for LHB tenodesis are inconsistently reported, the most common indications include LHB tearing, instability, and tenosynovitis. Other indications include clinical exam indicating LHB pathology, SLAP tears and subjective shoulder pain. Rigorous reporting of indications and preoperative/operative findings should be emphasized in future studies, allowing surgeons to appropriately analyse outcomes of LHB tenodesis of different techniques within patient groups with distinct indications.

LEVEL OF EVIDENCE

Systematic review, Level IV.

Qualitative Assessment and Quantitative Analysis of the Long Head of the Biceps Tendon in Relation to the Pectoralis Major Tendon Humeral Insertion: An Anatomic Study

PURPOSE

To qualitatively assess and to quantitatively analyze the long head of the biceps tendon (LHBT) in the region of the pectoralis major (PM).

METHODS

From 11 fresh cadaveric donors, 20 cadaveric shoulders without operative scars were dissected-mean age, 76.9 years (range, 61 to 93 years); male, 75%; left-sided, 55%; mean height, 67.8 inches (range, 61 to 71 inches); mean weight, 148.1 pounds (range, 106 to 176 pounds). Two specimens with discovered ruptures were excluded. The LHBT circumference was measured at the anterior edge of supraspinatus, suprapectorally, midpectorally, and subpectorally. The muscle was then removed from the LHBT and the circumference was again measured at the supra-, mid-, and subpectoral levels. These data were used to calculate the area of the tendon. All measurements were performed by 2 independent observers. Statistical analysis was performed to assess reliability of data and the difference between serial measurements.

RESULTS

The mean calculated percentage tendon decreased from 86.7% at the superior edge of the PM to 49.8% at the midpoint of the PM and to 17.5% at the inferior edge of the PM.

CONCLUSIONS

Distal to the PM, the LHBT was composed of a small percentage of tendon to muscle, which may have implications for the mechanical strength of fixation of tenodesis. The anatomic location of the musculotendinous junction of the LHBT began proximal to the superior edge of the PM tendon, which implies that restoration of anatomic tensioning may require a more proximal docking site than previously described. Tenodesis performed between the midpoint of the PM insertion and more distal points involves a significant portion of muscle, which may not be optimal.

CLINICAL RELEVANCE

Tenodesis performed between the midpoint of the PM insertion and more distal points involves a significant portion of muscle, which may affect the mechanical strength or optimal choice of fixation location.

Direct repair of chronic distal biceps tendon tears

OBJECTIVE

To present the results from direct tendon repair using EndoButton and interference screws in patients with lesions of the distal biceps that had evolved over a period of more than 28 days.

METHODS

Between January 2012 and November 2013, eleven patients (all male) with a torn distal biceps and a time interval between injury and surgery of more than 28 days were evaluated. The patients' mean age was 46 years and the most common mechanism of injury was eccentric loading with the elbow flexed and supinated.

RESULTS

A subjective analysis on pain and function was conducted using a visual analog scale of pain (VAS) and the Mayo Elbow Performance Score (MEPS), before and after surgery. The VAS showed a decrease of 5 points to 0.8 points on average. The MEPS improved from 69.3 points before the operation to 97.5 points afterwards. The mean flexion was 133.1° on the operated side, versus 134.3°. The mean extension was -2.5° and 0° (operated side versus non-operated). Supination was 88.2° versus 89.5° and pronation was 82.5° versus 84.1°, comparing the operated side versus the non-operated side. Flexion and supination strengths were evaluated with the aid of a dynamometer, and the mean flexion and supination strengths were found to be respectively 78.57% and 89.65% of the strength of the non-operated limb.

CONCLUSION

Use of the technique of direct tendon repair using EndoButton and interference screws was shown to be a safe and effective alternative for repairing chronic lesions of the distal biceps.

Rupture of the Long Head of the Biceps Tendon in a Pediatric Athlete: A Case Report

CASE

We report a case of an adolescent athlete who sustained an isolated rupture of the long head of the biceps tendon and was subsequently treated with subpectoral biceps tenodesis.

CONCLUSION

Provided that there is no damage to the rotator cuff, an open biceps tenodesis may be performed in this young patient population with good short-term outcomes and return to full activity.

Arthroscopic versus open comparison of long head of biceps tendon visualization and pathology in patients requiring tenodesis

PURPOSE

The purpose of this study was to compare arthroscopic versus open examination of the proximal long head of the biceps tendon (LHB) in patients undergoing open, subpectoral tenodesis.

METHODS

Eighty consecutive patients were prospectively enrolled, of whom 62 were included in the study. During arthroscopy, the most distal extent of the LHB visualized was marked with a Bovie device. The tendon was pulled into the joint with an arthroscopic grasper, showing additional LHB and was again marked with the device. LHB fraying, flattening, redness, and degeneration were graded as absent, mild, moderate, or severe. During open subpectoral tenodesis, the grossly visualized LHB was graded in the same manner and the locations of both marks plus the total length of the LHB observed during open visualization were measured and recorded. After subpectoral tenodesis, the excised portion of the LHB was histologically graded as normal, fibrosis/tendinosis, or inflamed.

RESULTS

On average, during open tenodesis, 95 mm (range, 75 to 130 mm) of LHB was visualized. This was greater than the length visualized during diagnostic arthroscopy of 16 mm (range, 5 to 28 mm), or 17%, and the length visualized while pulling the tendon into the joint with an arthroscopic grasper of 30 mm (range, 15 to 45 mm), or 32%. The difference in LHB length observed during open versus arthroscopic examination with a grasper was statistically significant (P < .0001). In addition, when compared with LHB pathology observed in an open manner, arthroscopic visualization showed only 67% of pathology, underestimated noted pathology in 56% of patients, and overestimated noted pathology in 11% of patients. Histologic evaluation showed fibrosis/tendinosis in 100% of cases but inflammation in only 5%.

CONCLUSIONS

When compared with open inspection during subpectoral tenodesis, arthroscopic examination of the LHB visualizes only 32% of the tendon and may underestimate pathology.

LEVEL OF EVIDENCE

Level II, diagnostic study-development of diagnostic criteria based on consecutive patients with universally applied gold standard.

Analysis of "hidden lesions" of the extra-articular biceps after subpectoral biceps tenodesis: the subpectoral portion as the optimal tenodesis site

BACKGROUND

In biceps tenodesis for intra-articular tears, determining the distal extension of the lesions through the biceps groove is important in choosing the optimal tenodesis site.

PURPOSE

To determine the optimal tenodesis site by analyzing the extension and delamination of an extra-articular lesion, or a "hidden lesion," in the retrieved biceps after subpectoral biceps tenodesis.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A total of 36 subpectoral tenodeses were performed, and the retrieved biceps were analyzed. The biceps lesions were divided into zones according to their location as follows: the proximal intra-articular (zone A), middle intragroove (zone B), and distal extra-articular portions (zone C); the lesions in zones B and C were called "hidden lesions." The length and delamination depth of the biceps tears were examined, and the severity of the accompanying tenosynovitis and degeneration was assessed.

RESULTS

Tears invaded zone B in all the cases and extended to zone C in 28 cases (77.8%). Tenosynovitis was observed along the tear in 28 cases (77.8%) and extended to zone C in 26 cases (72.2%). The mean tear length in the hidden lesions, including the tear and tenosynovitis, was 34.2 mm. Degenerative changes in the proximal intra-articular and middle intragroove portions were observed in all the cases and up to the distal extra-articular portion in 29 cases (80.6%).

CONCLUSION

In approximately 80% of the intra-articular biceps tears evaluated in this study, a "hidden lesion" was observed going beyond the bicipital groove and extending to the distal extra-articular portion. Therefore, the subpectoral portion may be considered the optimal tenodesis site for the complete removal of all hidden biceps lesions.