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Fox JA, Luther L, Epner E, LeClere L. Shoulder Proprioception: A Review. J Clin Med 2024; 13:2077. [PMID: 38610841 PMCID: PMC11012644 DOI: 10.3390/jcm13072077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 03/03/2024] [Accepted: 03/27/2024] [Indexed: 04/14/2024] Open
Abstract
The purpose of this review is to provide a comprehensive resource for shoulder proprioception assessment and its integration into clinical decision making as well as targeted rehabilitation protocols. Data for this review were acquired from peer-reviewed articles from computerized online databases, namely PubMed and Medline, published between 1906 and 2021. The development of digital/smart phone goniometers can improve shoulder joint range of motion (ROM) measurements and demonstrate comparable measurement accuracy to the universal standard goniometer. The inclinometer offers a portable and cost-effective method for measuring shoulder joint angles and arcs of motion in the vertical plane. Two types of dynamometers, the computerized isokinetic machine and the handheld hydraulic dynamometer, are reliable tools for objective shoulder rotator cuff strength assessment. Motion analysis systems are highly advanced modalities that create three-dimensional models of motion arcs using a series of cameras and reflective beads, offering unparalleled precision in shoulder proprioception measurement; however, they require time-consuming calibration and skilled operators. Advancements in wearable devices and compact mobile technology such as iPhone applications may make three-dimensional motion analysis more affordable and practical for outpatient settings in the future. The complex interplay between proprioception and shoulder dysfunction is not fully understood; however, shoulder proprioception can likely both contribute to and be caused by shoulder pathology. In patients with rotator cuff tears, glenohumeral osteoarthritis, and shoulder instability, clinicians can track proprioception to understand a patient's disease progression or response to treatment. Finally, rehabilitation programs targeting shoulder proprioception have shown promising initial results in restoring function and returning athletes to play.
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Affiliation(s)
| | | | - Eden Epner
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, 1215 21st Ave S Ste 3200, Nashville, TN 37232, USA; (J.A.F.); (L.L.); (L.L.)
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Winkler S, Herbst B, Kafchitsas K, Wohlmuth P, Hoffstetter P, Rueth MJ. Pre-operative Assessment of Shoulder Pathologies on MRI by a Radiologist and an Orthopaedic Surgeon. Malays Orthop J 2024; 18:42-50. [PMID: 38638663 PMCID: PMC11023335 DOI: 10.5704/moj.2403.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 05/03/2023] [Indexed: 04/20/2024] Open
Abstract
Introduction Pathologies of the shoulder, i.e. rotator cuff tears and labral injuries are very common. Most patients receive MRI examination prior to surgery. A correct assessment of pathologies is significant for a detailed patient education and planning of surgery. Materials and methods Sixty-nine patients were identified, who underwent both, a standardised shoulder MRI and following arthroscopic shoulder surgery in our hospital. For this retrospective comparative study, the MRIs were pseudonymised and evaluated separately by an orthopaedic surgeon and a radiologist. A third rater evaluated images and reports of shoulder surgery, which served as positive control. Results of all raters were then compared. The aim was an analysis of agreement rates of diagnostic accuracy of preoperative MRI by a radiologist and an orthopaedic surgeon. Results The overall agreement with positive control of detecting transmural cuff tears was high (84% and 89%) and lower for partial tears (70-80%). Subscapularis tears were assessed with moderate rates of agreement (60 - 70%) compared to intra-operative findings. Labral pathologies were detected mostly correctly. SLAP lesions and pulley lesions of the LHB were identified with only moderate agreement (66.4% and 57.2%) and had a high inter-rater disagreement. Conclusion This study demonstrated that tears of the rotator cuff (supraspinatus, infraspinatus) and labral pathologies can be assessed in non-contrast pre-operative shoulder MRI images with a high accuracy. This allows a detailed planning of surgery and aftercare. Pathologies of the subscapularis tendon, SLAP lesions and biceps instabilities are more challenging to detect correctly. There were only small differences between a radiologic and orthopaedic interpretation of the images.
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Affiliation(s)
- S Winkler
- Department of Orthopaedic Surgery, Asklepios Hospital Lindenlohe, Schwandorf, Germany
| | - B Herbst
- Department of Orthopaedic Surgery, Asklepios Hospital Lindenlohe, Schwandorf, Germany
| | - K Kafchitsas
- Department of Orthopaedic Surgery, Asklepios Hospital Lindenlohe, Schwandorf, Germany
| | - P Wohlmuth
- Department of Research, ASKLEPIOS Proresearch, Hamburg, Germany
| | - P Hoffstetter
- Department of Radiology, University of Regensburg, Regensburg, Germany
| | - M J Rueth
- Department Sports Clinic, Sportklinik Fichtelgebirge, Markredwitz, Germany
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Shin KH, Jang IT, Han SB. Outcomes of Superior Capsular Reconstruction Using the Long Head of the Biceps Tendon in Large to Massive Rotator Cuff Tears: A Meta-Analysis and Systematic Review. J Clin Med 2024; 13:1052. [PMID: 38398365 PMCID: PMC10889218 DOI: 10.3390/jcm13041052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 01/26/2024] [Accepted: 02/09/2024] [Indexed: 02/25/2024] Open
Abstract
(1) Background: Addressing large to massive rotator cuff tears (LMRCTs) poses complex challenges. This systematic review investigated outcomes of superior capsular reconstruction (SCR) with the long head of the biceps tendon (LHBT) compared to conventional rotator cuff repair (RCR) for LMRCTs. (2) Methods: A systematic search across the MEDLINE/PubMed, EMBASE, Cochrane Library, and Scopus databases until 1 October 2023 identified studies that directly compared SCR with LHBT with conventional RCR in patients with LMRCTs and included a minimum of a 12-month follow-up period. The assessed outcome measures encompassed retear rates, functional outcomes, range of motion (ROM), and acromiohumeral interval (AHI). Risk of bias assessment was conducted via the Robins-I tool. (3) Results: In six studies with 456 cases (210 SCR using LHBT and 246 using RCR), SCR with LHBT significantly reduced retear rates (OR = 0.21; 95% CI, 0.12-0.36; p < 0.01; I2 = 0%). Furthermore, SCR with LHBT showed significant improvement in range of forward flexion (SMD 0.32, 95% CI: 0.09-0.55, p < 0.01, I2 = 39%) and AHI (SMD 0.61, 95% CI: 0.31-0.92, p < 0.01, I2 = 0%) postoperatively. (4) Conclusion: SCR with LHBT is a safe and effective treatment for LMRCTs, reducing retear rates, maintaining greater postoperative AHI, and improving ROM compared to conventional RCR. Additional high-quality interventional studies are needed to confirm these results.
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Affiliation(s)
- Kyun-Ho Shin
- Department of Orthopedic Surgery, Yeson Hospital, Bucheon-si 14555, Republic of Korea
| | - Il-Tae Jang
- Nanoori Medical Research Institute, Seoul 06048, Republic of Korea;
| | - Seung-Beom Han
- Department of Orthopedic Surgery, Anam Hospital, Korea University College of Medicine, Seoul 02841, Republic of Korea;
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Wang Y, Geng L, Zhao R, Yang J, Cheng L, Xin P, Wang Y, Zhang G. Extra-articular biceps tendon supplement release in total knee arthroplasty for valgus deformity combined with severe flexion contracture. J Orthop Res 2023; 41:2433-2441. [PMID: 37186321 DOI: 10.1002/jor.25578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 04/13/2023] [Accepted: 04/17/2023] [Indexed: 05/17/2023]
Abstract
To investigate the efficacy of extra-articular biceps tendon supplement (EBS) release in the treatment of valgus knee with severe flexion contracture. We retrospectively studied 27 patients who received EBS release for valgus knee combined with severe flexion contracture from 2018 to 2021. The full-length radiograph of the lower limbs in a standing position was taken before and after the operation, and the tibiofemoral angles before and after the operation were measured on the full-length radiograph of the lower limbs. Knee joint motion measurement and KSS scoring were performed before and after the operation (3 months, 6 months, and 1 year), and the obtained data were compared before and after the operation to evaluate clinical results. Compared with preoperation, postoperative HKA (p < 0.01), ROM at 3 months (p < 0.01), 6 months (p < 0.01), and 1 year (p < 0.01) were significantly improved, and KSS scores at 3 months (p < 0.01), 6 months (p < 0.01), and 1 year (p < 0.01) were significantly improved. Our EBS release has good clinical results for the treatment of valgus knee with severe flexion contracture.
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Affiliation(s)
- Yiming Wang
- Medical School of Chinese PLA, Beijing, China
- Department of Orthopedics, The First Medical Center of PLA General Hospital, Beijing, China
- Senior Department of Orthopedics, The Fourth Medical Center of PLA General Hospital, Beijing, China
| | - Lei Geng
- Department of Orthopedics, The First Medical Center of PLA General Hospital, Beijing, China
- Senior Department of Orthopedics, The Fourth Medical Center of PLA General Hospital, Beijing, China
| | - Runkai Zhao
- Medical School of Chinese PLA, Beijing, China
- Department of Orthopedics, The First Medical Center of PLA General Hospital, Beijing, China
- Senior Department of Orthopedics, The Fourth Medical Center of PLA General Hospital, Beijing, China
| | - Jianfeng Yang
- Medical School of Chinese PLA, Beijing, China
- Department of Orthopedics, The First Medical Center of PLA General Hospital, Beijing, China
- Senior Department of Orthopedics, The Fourth Medical Center of PLA General Hospital, Beijing, China
| | - Long Cheng
- Medical School of Chinese PLA, Beijing, China
- Department of Orthopedics, The First Medical Center of PLA General Hospital, Beijing, China
- Senior Department of Orthopedics, The Fourth Medical Center of PLA General Hospital, Beijing, China
| | - Peng Xin
- Medical School of Chinese PLA, Beijing, China
- Department of Orthopedics, The First Medical Center of PLA General Hospital, Beijing, China
- Senior Department of Orthopedics, The Fourth Medical Center of PLA General Hospital, Beijing, China
| | - Yan Wang
- Department of Orthopedics, The First Medical Center of PLA General Hospital, Beijing, China
- Senior Department of Orthopedics, The Fourth Medical Center of PLA General Hospital, Beijing, China
| | - Guoqiang Zhang
- Department of Orthopedics, The First Medical Center of PLA General Hospital, Beijing, China
- Senior Department of Orthopedics, The Fourth Medical Center of PLA General Hospital, Beijing, China
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Kim DS, Han JY, Park YJ, Kwak JW, Lee BS. Comparative analysis of superior capsule reconstruction between long head of biceps tendon autograft and human dermis allograft. J Shoulder Elbow Surg 2023; 32:820-831. [PMID: 36174817 DOI: 10.1016/j.jse.2022.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 07/18/2022] [Accepted: 08/11/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Although many superior capsule reconstruction (SCR) techniques are currently practiced in clinical settings, guidelines for choosing the appropriate graft material are lacking. Therefore, at most times, the surgeon's personal preference becomes the deciding factor. This study compared 2 fairly recent SCR techniques-SCR with biceps tendon (BT) autograft and SCR with human dermis (HD) allograft-by evaluating clinical and radiologic outcomes to aid the surgeon's decision in choosing the appropriate graft. METHODS Thirty-one patients underwent SCR using BT autograft (SCR BT), and 22 underwent SCR using HD allograft (SCR HD). SCR BT was selected for patients with a partial BT tear <20%, no severe inflammation signs, and favorable anchor conditions. SCR HD was performed in patients with a BT tear >20%, a superior labrum anterior-posterior (SLAP) lesion, severe inflammation, or subluxation. Range of motion (ROM), strength and shoulder function scoring, plain radiography, and magnetic resonance imaging were evaluated before and after surgery at regular intervals. RESULTS In the SCR BT group, forward flexion ROM increased from 122° ± 43° to 149° ± 18° at 2 years postoperatively, whereas in the SCR HD group, forward flexion ROM improved from 129° ± 28° to 149° ± 18°. In the SCR BT group, internal rotation (IR) ROM increased from 5 ± 3 to 6 ± 2 at 2 years postoperatively, whereas in the SCR HD group, IR ROM improved from 5 ± 3 to 6 ± 1. Although ROM, strength, visual analog scale score, American Shoulder and Elbow Surgeons score, and Constant score all improved 2 years after surgery, no statistically significant differences were found. Six months after surgery, graft thickness was 3.58 ± 0.384 mm in the SCR BT group and 2.49 ± 0.326 mm in the SCR HD group (P < .001). At 2 years postoperatively, graft thickness was 3.54 ± 0.399 mm in the SCR BT group and 2.49 ± 0.306 mm in the SCR HD group (P < .001). The SCR HD group showed a negative correlation of -0.475 between graft thickness and IR ROM (P = .026). In the SCR BT group, a negative correlation of -0.466 was found between graft thickness and IR ROM (P = .008). A positive correlation of 0.363 was found between IR ROM and the acromiohumeral distance when the results were compared before and 2 years after surgery (P = .045). CONCLUSION Both SCR using BT autograft and SCR using HD allograft tissue showed favorable results, and no significant difference was noted between the 2 techniques. Given that the 2 techniques show equally favorable results, the surgeon's personal preference in choosing the SCR technique appears to be acceptable. Understanding the costs and patient's characteristics may aid the surgeon in deciding on the graft material.
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Affiliation(s)
- Doo Sup Kim
- Department of Orthopedic Surgery, Wonju College of Medicine, Yonsei University, Wonju Severance Christian Hospital, Wonju, Republic of Korea
| | - Jin Young Han
- Department of Orthopedic Surgery, Wonju College of Medicine, Yonsei University, Wonju Severance Christian Hospital, Wonju, Republic of Korea.
| | - Yeon Jae Park
- Department of Medical Statistics, Wonju College of Medicine, Yonsei University, Wonju Severance Christian Hospital, Wonju, Republic of Korea
| | - Ji Woong Kwak
- Department of Orthopedic Surgery, Wonju College of Medicine, Yonsei University, Wonju Severance Christian Hospital, Wonju, Republic of Korea
| | - Bum Seok Lee
- Department of Orthopedic Surgery, Wonju College of Medicine, Yonsei University, Wonju Severance Christian Hospital, Wonju, Republic of Korea
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Zhang C, Yang G, Li T, Pang L, Li Y, Yao L, Li R, Tang X. 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. [PMID: 36902540 DOI: 10.3390/jcm12051754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [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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Sandler AB, Childs BR, Scanaliato JP, Dunn JC, Parnes N. SLAP Repair Versus Biceps Tenodesis in Patients Younger Than 40 Years: A Cost-Effectiveness Analysis. Orthop J Sports Med 2022; 10:23259671221140364. [PMID: 36479458 PMCID: PMC9720817 DOI: 10.1177/23259671221140364] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 09/15/2022] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND The surgical management of type II superior labrum anterior and posterior (SLAP) tears in patients younger than 40 years is controversial, but growing evidence suggests comparable outcomes between primary SLAP repair and primary biceps tenodesis, with lower rates of reoperations after primary biceps tenodesis. Given the relatively similar patient-reported outcomes, cost-effectiveness analyses of direct and indirect costs associated with the two procedures propound a valuable comparative technique. HYPOTHESIS In this value-based comparison of SLAP repair versus biceps tenodesis, we hypothesized that biceps tenodesis would be more cost-effective than SLAP repair in patients younger than 40 years. STUDY DESIGN Economic and decision analysis; Level of evidence, 4. METHODS A 1-month Markov cycle was simulated to reflect 10 years of health outcomes. Health states were selected based on outcomes that are especially important in assessing indirect costs for a younger, active patient population: return-to-sport rates, which demonstrate a return to baseline function, and reoperation rates. Transition state probabilities were obtained through an index systematic review and meta-analysis comparing labral repair and biceps tenodesis for the treatment of type II SLAP lesions in patients younger than 40 years. Health state utility and cost values were obtained from accepted values denoted in existing literature. RESULTS Both primary SLAP repair and primary biceps tenodesis yielded an average expected 8.1 quality-adjusted life years over the 10-year period. The average cost (in 2021 US$) was $16,619 for biceps tenodesis and $19,388 for SLAP repair. CONCLUSION In a younger patient population, SLAP repair and biceps tenodesis had comparable quality-adjusted life years and utility in the treatment of type II SLAP tears; however, SLAP repair cost $19,388, while biceps tenodesis cost $16,619, reflecting a 14% cost savings with biceps tenodesis. These findings can be extrapolated to further establish the role for these procedures in treating SLAP tears.
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Affiliation(s)
- Alexis B. Sandler
- Department of Orthopaedics, William Beaumont Army Medical Center/Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
| | - Benjamin R. Childs
- Department of Orthopaedics, William Beaumont Army Medical Center/Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
| | - John P. Scanaliato
- Department of Orthopaedics, William Beaumont Army Medical Center/Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
| | - John C. Dunn
- Department of Orthopaedics, William Beaumont Army Medical Center/Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
| | - Nata Parnes
- Department of Orthopedic Surgery, Carthage Area Hospital, Carthage, New York, USA
- Department of Orthopedics, Claxton-Hepburn Medical Center, Ogdensburg, New York, USA
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Park JH, Park KT, Kim SC, Bukhary HA, Lee SM, Yoo JC. Arthroscopic biceps augmentation does not improve clinical outcomes during incomplete repair of large to massive rotator cuff tears. Bone Joint J 2022; 104-B:1234-1241. [PMID: 36317346 DOI: 10.1302/0301-620x.104b11.bjj-2022-0422.r2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
AIMS This study compared patients who underwent arthroscopic repair of large to massive rotator cuff tears (LMRCTs) with isolated incomplete repair of the tear and patients with incomplete repair with biceps tendon augmentation. We aimed to evaluate the additional benefit on clinical outcomes and the capacity to lower the re-tear rate. METHODS We retrospectively reviewed 1,115 patients who underwent arthroscopic rotator cuff repair for full-thickness tears between October 2011 and May 2019. From this series, we identified 77 patients (28 male, 49 female) with a mean age of 64.1 years (50 to 80). Patients were classified into groups A (n = 47 incomplete) and B (n = 30 with biceps augmentation) according to the nature of their reconstruction. Clinical scores were checked preoperatively and at six months, one year, and two years postoperatively. In preoperative MRI, we measured the tear size, the degree of fatty infiltration, and muscle volume ratio of the supraspinatus. In postoperative MRI, the integrity of the repaired rotator cuff tendon was assessed using the Sugaya classification. Tendon thickness at the footprint was evaluated on T2-weighted oblique coronal view. RESULTS There were no significant differences in the initial preoperative demographic characteristics. In both groups, there were significant improvements in postoperative clinical scores (p < 0.001). However, most clinical outcomes, including range of motion measurements (forward elevation, external rotation, internal rotation, and abduction), showed no differences between the pre- and postoperative values. Comparing the postoperative outcomes of both groups, no further improvement from biceps augmentation was found. Group B, although not reaching statistical significance, had more re-tears than group A (30% vs 15%; p = 0.117). CONCLUSION In LMRCTs, biceps augmentation provided no significant improvement of an incomplete repair. Therefore, biceps augmentation is not recommended in the treatment of LMRCTs.Cite this article: Bone Joint J 2022;104-B(11):1234-1241.
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Affiliation(s)
- Jong H Park
- Department of Orthopaedic Surgery, Samsung Medical Center, Seoul, South Korea
| | - Kun T Park
- Department of Orthopaedic Surgery, Samsung Medical Center, Seoul, South Korea
| | - Su C Kim
- Department of Orthopaedic Surgery, Samsung Medical Center, Seoul, South Korea
| | - Hashem A Bukhary
- Department of Orthopaedic Surgery, Samsung Medical Center, Seoul, South Korea
- Department of Orthopaedic Division, Taif University Faculty of Medicine, Taif, Saudi Arabia
| | - Sang M Lee
- Department of Orthopaedic Surgery, Samsung Medical Center, Seoul, South Korea
| | - Jae C Yoo
- Department of Orthopaedic Surgery, Samsung Medical Center, Seoul, South Korea
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McDevitt AW, Cleland JA, Addison S, Calderon L, Snodgrass S. Physical Therapy Interventions for the Management of Biceps Tendinopathy: An International Delphi Study. Int J Sports Phys Ther 2022; 17:677-694. [PMID: 35693861 PMCID: PMC9159730 DOI: 10.26603/001c.35256] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 03/24/2022] [Indexed: 11/18/2022] Open
Abstract
Background Shoulder pain related to the long head of the biceps tendon (LHBT) tendinopathy can be debilitating and difficult to treat especially in athletes who often elect for surgical intervention. Conservative management is recommended but there are limited established guidelines on the physical therapy (PT) management of the condition. Hypothesis/Purpose The purpose of this study was to establish consensus on conservative, non-surgical physical therapy interventions for individuals with LHBT tendinopathy using the Delphi method approach. Study Design Delphi Study. Methods Through an iterative process, experts in the PT field rated their agreement with a list of proposed treatment interventions and suggested additional interventions during each round. Agreement was measured using a four-point Likert scale. Descriptive statistics including median and percentage agreement were used to measure agreement. Data analysis at the end of Round III produced, by consensus, a list of PT interventions recommended for the management of individuals with LHBT tendinopathy. Consensus was defined as an a priori cutoff of ≥75% agreement. Results The respondent group included 29 international experts in the PT management of individuals with shoulder pain. At the conclusion of the study 61 interventions were designated as recommended based on consensus amongst experts and 9 interventions were not recommended based on the same criteria, 15 interventions did not achieve consensus. Conclusion There is a lack of well-defined, PT interventions used to treat LHBT tendinopathy. Expert respondents reached consensus on multimodal interventions including exercise, manual therapy and patient education to manage LHBT tendinopathy. Level of Evidence 5.
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Affiliation(s)
- Amy W McDevitt
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus; The University of Newcastle
| | - Joshua A Cleland
- Department of Public Health and Community Medicine, Doctor of Physical Therapy Program, Tufts University School of Medicine
| | - Simone Addison
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus
| | - Leah Calderon
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus
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Colbath G, Murray A, Siatkowski S, Pate T, Krussig M, Pill S, Hawkins R, Tokish J, Mercuri J. Autograft Long Head Biceps Tendon Can Be Used as a Scaffold for Biologically Augmenting Rotator Cuff Repairs. Arthroscopy 2022; 38:38-48. [PMID: 34126215 PMCID: PMC8665938 DOI: 10.1016/j.arthro.2021.05.064] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 05/23/2021] [Accepted: 05/31/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE We create a viable, mechanically expanded autograft long head biceps tendon (LHBT) scaffold for biologically augmenting the repair of torn rotator cuffs. METHODS The proximal aspect of the tenotomized LHBTs was harvested from patients during rotator cuff repair surgery and was mechanically formed into porous scaffolds using a surgical graft expander. LHBT scaffolds were evaluated for change in area, tensile properties, and tenocyte viability before and after expansion. The ability of endogenous tenocytes derived from the LHBT scaffold to promote tenogenic differentiation of human adipose-derived mesenchymal stromal cells (ADMSCs) was also determined. RESULTS Autograft LHBTs were successfully expanded using a modified surgical graft expander to create a porous scaffold containing viable resident tenoctyes from patients undergoing rotator cuff repair. LHBT scaffolds had significantly increased area (length: 24.91 mm [13.91, 35.90] × width: 22.69 mm [1.87, 34.50]; P = .011) compared with the native LHBT tendon (length: 27.16 mm [2.70, 33.62] × width: 6.68 mm [5.62, 7.74]). The structural properties of the autograft were altered, including the ultimate tensile strength (LHBT scaffold: .56 MPa [.06, 1.06] vs. native LHBT: 2.35 MPa [1.36, 3.33]; P = .002) and tensile modulus (LHBT scaffold: 4.72 MPa [-.80, 1.24] versus native LHBT: 37.17 MPa [24.56, 49.78]; P = .001). There was also a reduction in resident tenocyte percent viability (LHBT scaffold: 38.52% [17.94, 59.09] vs. native LHBT: 68.87% [63.67, 74.37]; P =.004). Tenocytes derived from the LHBT scaffold produced soluble signals that initiated ADMSC differentiation into an immature tenocyte-like phenotype, as indicated by an 8.7× increase in scleraxis (P = .040) and a 3.6× increase in collagen type III mRNA expression (P = .050) compared with undifferentiated ADMSC controls. CONCLUSIONS The ability to produce a viable autologous scaffold from the proximal biceps tendon having dimensions, porosity, mechanical characteristics, native ECM components, and viable tenocytes that produce bioactive signals conducive to supporting the biologic augmentation of rotator cuff repair surgery has been demonstrated. CLINICAL RELEVANCE This biologically active construct may help to improve the quality of healing and regeneration at the repair site of rotator cuff tears, especially those at high risk for retear.
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Affiliation(s)
- Gregory Colbath
- Medical Group of the Carolinas, Department of Orthopaedic Surgery, Spartanburg Regional, Spartanburg, SC
| | - Alison Murray
- Laboratory of Orthopaedic Tissue Regeneration & Orthobiologics, Department of Bioengineering, Clemson University, Clemson, SC,Frank H. Stelling and C. Dayton Riddle Orthopaedic Education and Research Laboratory, Clemson University Biomedical Engineering Innovation Campus, Greenville, SC
| | - Sandra Siatkowski
- Laboratory of Orthopaedic Tissue Regeneration & Orthobiologics, Department of Bioengineering, Clemson University, Clemson, SC,Frank H. Stelling and C. Dayton Riddle Orthopaedic Education and Research Laboratory, Clemson University Biomedical Engineering Innovation Campus, Greenville, SC
| | - Taylor Pate
- Laboratory of Orthopaedic Tissue Regeneration & Orthobiologics, Department of Bioengineering, Clemson University, Clemson, SC,Frank H. Stelling and C. Dayton Riddle Orthopaedic Education and Research Laboratory, Clemson University Biomedical Engineering Innovation Campus, Greenville, SC
| | - Mario Krussig
- Laboratory of Orthopaedic Tissue Regeneration & Orthobiologics, Department of Bioengineering, Clemson University, Clemson, SC,Frank H. Stelling and C. Dayton Riddle Orthopaedic Education and Research Laboratory, Clemson University Biomedical Engineering Innovation Campus, Greenville, SC
| | - Stephan Pill
- Steadman Hawkins Clinic of the Carolinas, Department of Orthopaedic Surgery, Prisma Health, Greenville, SC
| | - Richard Hawkins
- Steadman Hawkins Clinic of the Carolinas, Department of Orthopaedic Surgery, Prisma Health, Greenville, SC
| | - John Tokish
- Mayo Clinic, Department of Orthopaedic Surgery, Phoenix, AZ
| | - Jeremy Mercuri
- Laboratory of Orthopaedic Tissue Regeneration & Orthobiologics, Department of Bioengineering, Clemson University, Clemson, SC,Frank H. Stelling and C. Dayton Riddle Orthopaedic Education and Research Laboratory, Clemson University Biomedical Engineering Innovation Campus, Greenville, SC
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11
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Kim BR, Lee J, Ahn JM, Kang Y, Lee E, Lee JW, Kang HS. Predicting the clinically significant subscapularis tendon tear: malposition and tear of the long head of the biceps tendon on shoulder magnetic resonance imaging. Acta Radiol 2021; 62:1648-1656. [PMID: 33325726 DOI: 10.1177/0284185120980017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The diagnostic accuracy of magnetic resonance imaging (MRI) is low for detecting a subscapularis tendon tear. PURPOSE To identify MRI findings that may predict the presence of a clinically significant subscapularis tendon tear requiring surgical repair. MATERIAL AND METHODS We reviewed shoulder MR images of patients who had undergone arthroscopic rotator cuff repair at our institution between June 2018 and May 2019. Patients were divided into two groups: the study group (n = 51), with an intermediate- to high-grade partial thickness tear of the subscapularis tendon suspected on preoperative MRI and intermediate or higher grade of the tendon tear proven on arthroscopy; and the control group (n = 18), with an intermediate- to high-grade partial thickness tear of the subscapularis tendon suspected on preoperative MRI but no tear or low-grade partial thickness tear of the tendon shown on arthroscopy. Preoperative MR images were retrospectively evaluated by two readers for the size of the subscapularis tendon tear, bone reactions at the lesser tuberosity, and long head of the biceps tendon (LHBT) pathology. RESULTS The subscapularis tendon tear measured by reader 2 was larger in the study group than in the control group. The prevalence of a tear (P = 0.006 for reader 1; P = 0.011 for reader 2) and malposition (P < 0.001 for both readers) of the LHBT were significantly greater in the study group. CONCLUSION A tear and malposition of the LHBT on MR images may predict the presence of a clinically significant subscapularis tendon tear.
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Affiliation(s)
- Bo Ra Kim
- Department of Radiology, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Jaehyung Lee
- Department of Radiology, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Joong Mo Ahn
- Department of Radiology, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Yusuhn Kang
- Department of Radiology, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Eugene Lee
- Department of Radiology, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Joon Woo Lee
- Department of Radiology, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Heung Sik Kang
- Department of Radiology, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
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12
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Björnsson Hallgren HC, Holmgren T. Good outcome after repair of trauma-related anterosuperior rotator cuff tears-a prospective cohort study. J Shoulder Elbow Surg 2021; 30:1636-1646. [PMID: 33069905 DOI: 10.1016/j.jse.2020.09.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 09/08/2020] [Accepted: 09/21/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Anterosuperior rotator cuff tears with a displaced long head of the biceps tendon are most often trauma-related, and patients with these conditions often present with severe pain and shoulder dysfunction. Repair of the subscapularis and supraspinatus and a biceps tenodesis or a tenotomy are the recommended treatments based on retrospective studies. The aim of this study was to prospectively evaluate clinical and structural treatment outcome in a cohort of trauma-related anterosuperior injuries in patients with previously healthy shoulders. MATERIALS AND METHODS Patients seeking care for a suspected rotator cuff injury after shoulder trauma were screened according to a protocol including clinical examination, baseline scoring with Western Ontario Rotator Cuff Index (WORC) and numeric rating scale of pain, ultrasound, and magnetic resonance imaging (MRI). Those with anterosuperior injuries were offered surgical treatment, structured postoperative physiotherapy, and inclusion in the present study with 1-year follow-up, including MRI, baseline scores, Constant-Murley score, and Patient Global Impression of Change. Thirty-three patients (78% men) with a mean age of 59 (40-76) years were included. RESULTS All patients had a biceps pulley lesion, a displaced biceps tendon, and incomplete full-thickness subscapularis and supraspinatus tears. Six patients declined surgery. At follow-up, the operated patients reached a median WORC score of 86% and a median change from baseline to follow-up of 50% (P = .0001). Pain decreased (P = .0001) at rest, at night, and during activity. The median Constant-Murley score was 86% of the contralateral nonoperated shoulder, 58% of the contralateral abduction strength recovered after surgery, and 86% reported that they were recovered or much improved. All repairs and tenodeses healed except for 2 supraspinatus tendons. The 6 nonoperated patients reached a median WORC score of 90, a change in the median value from baseline to follow-up of 31, but reported more pain, and a smaller proportion considered themselves as recovered or much improved. In all patients, the 1-year MRIs had signal changes in the upper muscular portion of subscapularis, consistent with fatty infiltration, regardless of operative or nonoperative treatment. CONCLUSION Anterosuperior rotator cuff injury with an associated pulley lesion and displaced long head of the biceps tendon may be treated successfully with surgery as the majority of patients in our cohort clinically recovered or were much improved without pain after a year. With a 1-year perspective, nonoperatively treated patients may also reach a reasonable clinical outcome. Independently of treatment or tendon healing, residual subscapularis muscle injury was seen, which may have long-term implications.
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Affiliation(s)
- Hanna C Björnsson Hallgren
- Department of Orthopaedics in Linköping and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.
| | - Theresa Holmgren
- Department of Orthopaedics in Linköping and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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13
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Keough N, Lorke DE. The humeral head: A review of the blood supply and possible link to osteonecrosis following rotator cuff repair. J Anat 2021; 239:973-982. [PMID: 34164802 PMCID: PMC8546514 DOI: 10.1111/joa.13496] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 06/03/2021] [Accepted: 06/09/2021] [Indexed: 11/28/2022] Open
Abstract
Trauma, corticosteroid therapy and metabolic diseases are well established aetiologies of humeral head osteonecrosis; however, there is increasing evidence that arthroscopic rotator cuff surgery may be another possible cause. One of the reasons is that there may be inadvertent damage to the arterial blood supply to the humeral head during surgical intervention. The blood supply to the humeral head displays large amounts of variation with regard to origin, course and distribution. Therefore, to shed light on the pathogenesis, the blood supply of the humeral head is reviewed together with a summary of all reported cases of osteonecrosis of the humeral head that occurred following rotator cuff repair. Inconsistencies with regard to terminologies used and contradictions concerning arterial contributions from the anterior circumflex humeral artery and the posterior circumflex humeral artery towards humeral head supply are addressed. Moreover, variations in the course of the anterior circumflex humeral artery and its branches are summarized. The vascular anatomy of the humeral head is clinically relevant due to the close relationship of these blood vessels with the surgical repair sites for rotator cuff surgery and biceps tenotomies or tenodesis procedures. Potential sites of disruption of blood supply following arthroscopic rotator cuff surgery are discussed. Detailed knowledge of the course of the arteries supplying the humeral head may help to minimize the risk of vascular injury and subsequent osteonecrosis. Given the great interindividual variations of vascular anatomy, imaging procedures preceding arthroscopic rotator cuff surgery may be advisable.
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Affiliation(s)
- Natalie Keough
- Department of Anatomy and Cellular Biology, College of Medicine and Health Sciences, Khalifa University, Abu Dhabi, United Arab Emirates.,Department of Anatomy, School of Medicine, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Dietrich E Lorke
- Department of Anatomy and Cellular Biology, College of Medicine and Health Sciences, Khalifa University, Abu Dhabi, United Arab Emirates.,Department of Cellular Biology and Pharmacology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
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14
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Kahan JB, Schneble CA, Applonie R, Nicholson A, Whittall I, Talley-Bruns R, Jorgensen A, LaVette N, Moran J, Ware JK, Lee FY, Blaine TA. Early success of the arthroscopic-assisted locked loop suprapectoral biceps tenodesis. JSES Rev Rep Tech 2021; 1:96-101. [PMID: 37588143 PMCID: PMC10426584 DOI: 10.1016/j.xrrt.2021.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
Background There is wide variability in surgical technique for biceps tenodesis. Prior biomechanical studies have demonstrated superior ultimate and fatigue strength with a Krakow-type locked loop when compared with simple suture and lasso-loop configurations; however, this had not yet been clinically studied. The purpose of this study was to assess the short-term results an arthroscopic-assisted locked loop (ALL) suprapectoral biceps tenodesis technique. Methods All patients who underwent an ALL suprapectoral biceps tenodesis by a single surgeon from 2012 and 2019 with a minimum of 12-month follow-up were analyzed. Data collected included demographics, surgical indications, concomitant operative procedures, and postoperative complications of anterior shoulder "groove" pain, "Popeye deformity," biceps muscle cramping pain, and need for revision surgery. Results Forty patients who underwent an ALL suprapectoral biceps tenodesis met inclusion criteria. Patients were 55.6 ± 8.6 years of age, consisting of 28 men (57%) and 21 women (43%). The median follow-up was 19.3 months. At the latest follow-up, 1 (2%) patient had anterior shoulder "groove" pain, and no patients had a Popeye deformity or biceps muscle cramping. There were no revision biceps tenodesis procedures. Conclusion The ALL suprapectoral biceps tenodesis technique results in a low incidence of postoperative complications. At a short-term follow-up of 1 year, no patients had reoperations or revisions for failed biceps tenodesis. Groove pain was nearly absent in this series of patients.
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Affiliation(s)
- Joseph B. Kahan
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | | | | | - Allen Nicholson
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Ian Whittall
- Department of Orthopaedic Surgery, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Rachel Talley-Bruns
- Department of Orthopaedic Surgery, Westchester Medical Center, Westchester, NY, USA
| | - Anna Jorgensen
- Department of Orthopaedic Surgery, University of Connecticut School of Medicine, Farmington, CT, USA
| | | | - Jay Moran
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | | | - Francis Y. Lee
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Theodore A. Blaine
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
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15
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Zabrzyński J, Gagat M, Łapaj Ł, Paczesny Ł, Yataganbaba A, Szwedowski D, Huri G. Relationship between long head of the biceps tendon histopathology and long-term functional results in smokers. A time to reevaluate the Bonar score? Ther Adv Chronic Dis 2021; 12:2040622321990262. [PMID: 33708369 PMCID: PMC7907713 DOI: 10.1177/2040622321990262] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 01/05/2021] [Indexed: 12/22/2022] Open
Abstract
Aim The purpose of this study was to investigate whether there is an association between smoking, the extent of the degeneration process in the biceps tendinopathy, including cells and extracellular matrix (ECM) alterations, and long-term surgical results. Methods This study comprised 40 consecutive patients admitted for shoulder arthroscopy due to symptomatic biceps tendinopathy and classified into three groups based on smoking status: active smokers, former smokers, and non-smokers. According to the classical Bonar score criteria, the histopathologic evaluation of the harvested intra-articular portion of the tendon was done. The follow-up examination was based on the American Shoulder and Elbow Surgeons Score (ASES). Results A cohort of 32 patients was enrolled in the final follow-up examination; mean 37.56 months. Histopathological evaluation according to the classical Bonar score revealed degeneration of the tendinous tissue in each group but there was no correlation between the extent of degeneration, smoking indexes and the ASES. After revision of Bonar scale within the vascularity criterion, we found a correlation between the extent of degeneration of tendinous tissue, smoking data, ASES score, and the severity of rotator cuff injury. Conclusion In this paper, we indicate the ambiguous role of the neovascularization in the biceps tendinopathy, and it was used for modification of the classical Bonar score. Consequently, recalculated, modified Bonar score was correlated positively with smoking indexes and functional outcomes. Furthermore, the morphological alterations of rotator cuff tendons also correlated positively with the extent of biceps tendon degeneration, measured according to the modified scoring system.
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Affiliation(s)
- Jan Zabrzyński
- Department of General Orthopedics, Musculoskeletal Oncology and Trauma Surgery, University of Medical Sciences, Poznan, Poland; Department of Orthopedics, Orvit Clinic, Citomed Healthcare Center, Torun, Poland
| | - Maciej Gagat
- Department of Histology and Embryology, Faculty of Medicine, Nicolaus Copernicus University in Torun, Collegium Medicum in Bydgoszcz, Torun, Poland
| | - Łukasz Łapaj
- Department of General Orthopedics, Musculoskeletal Oncology and Trauma Surgery, University of Medical Sciences, Poznan, Poland
| | - Łukasz Paczesny
- Department of Orthopedics, Orvit Clinic, Citomed Healthcare Center, Torun, Poland
| | - Alper Yataganbaba
- Orthopedics and Traumatology Department, Hacettepe Universitesi, Ankara, Turkey
| | - Dawid Szwedowski
- Department of Orthopedics, Orvit Clinic, Citomed Healthcare Center, Torun, Poland Orthopedic Arthroscopic Surgery International (OASI) Bioresearch Foundation Milan, Italy
| | - Gazi Huri
- Orthopedics and Traumatology Department, Hacettepe Universitesi, Ankara, Turkey
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16
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Kelly BJ, Reynolds AW, Schimoler PJ, Kharlamov A, Miller MC, Akhavan S. Measurements of Tendon Movement Within the Bicipital Groove After Suprapectoral Intra-articular Biceps Tenodesis in a Cadaveric Model. Orthop J Sports Med 2021; 9:2325967120977538. [PMID: 33553457 PMCID: PMC7829533 DOI: 10.1177/2325967120977538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 08/06/2020] [Indexed: 11/15/2022] Open
Abstract
Background Lesions of the long head of the biceps can be successfully treated with biceps tenotomy or tenodesis when surgical management is elected. The advantage of a tenodesis is that it prevents the potential development of a cosmetic deformity or cramping muscle pain. Proponents of a subpectoral tenodesis believe that "groove pain" may remain a problem after suprapectoral tenodesis as a result of persistent motion of the tendon within the bicipital groove. Purpose/Hypothesis To evaluate the motion of the biceps tendon within the bicipital groove before and after a suprapectoral intra-articular tenodesis. The hypothesis was that there would be minimal to no motion of the biceps tendon within the bicipital groove after tenodesis. Study Design Controlled laboratory study. Methods Six fresh-frozen cadaveric arms were dissected to expose the long head of the biceps tendon as well as the bicipital groove. Inclinometers and fiducials (optical markers) were used to measure the motions of the scapula, forearm, and biceps tendon through a full range of shoulder and elbow motions. A suprapectoral biceps tenodesis was then performed, and the motions were repeated. The motion of the biceps tendon was quantified as a function of scapular or forearm motion in each plane, both before and after the tenodesis. Results There was minimal motion of the native biceps tendon during elbow flexion and extension but significant motion during all planes of scapular motion before tenodesis, with the most motion occurring during shoulder flexion-extension (20.73 ± 8.21 mm). The motion of the biceps tendon after tenodesis was significantly reduced during every plane of scapular motion compared with the native state (P < .01 in all planes of motion), with a maximum motion of only 1.57 mm. Conclusion There was a statistically significant reduction in motion of the biceps tendon in all planes of scapular motion after the intra-articular biceps tenodesis. The motion of the biceps tendon within the bicipital groove was essentially eliminated after the suprapectoral biceps tenodesis. Clinical Relevance This arthroscopic suprapectoral tenodesis technique can significantly reduce motion of the biceps tendon within the groove in this cadaveric study, possibly reducing the likelihood of groove pain in the clinical setting.
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Affiliation(s)
- Brian J Kelly
- Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | | | | | | | | | - Sam Akhavan
- Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
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17
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Belk JW, Jones SD, Thon SG, Frank RM. Trends in the Treatment of Biceps Pathology: An Analysis of the American Board of Orthopaedic Surgery Database. Orthop J Sports Med 2020; 8:2325967120969414. [PMID: 33447620 PMCID: PMC7780327 DOI: 10.1177/2325967120969414] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 07/06/2020] [Indexed: 11/15/2022] Open
Abstract
Background: Long head of biceps tendon pathology is a well-described source of pain in the anterior adult shoulder. Shoulder arthroscopic surgeons face this condition on a frequent basis because of the increasing aging population. Trends in treatment for this condition have varied over recent decades. An understanding of these trends may help orthopaedic surgeons counsel these patients. Purpose: To evaluate trends in treatment selection, patient population, and complications in recent part II examinees of the American Board of Orthopaedic Surgery (ABOS) board examination. Study Design: Cross-sectional study. Methods: Using a database maintained by the ABOS, we accessed and analyzed examinee data from 2008 to 2019 to evaluate trends in the following categories: examination year/subspecialty, region, patient age/sex, International Classification of Diseases code, Current Procedural Terminology code, and complications. These data points were analyzed for all board-eligible candidates from 2008 to 2019. Results: The annual number of proximal biceps tendon (PBT) procedures performed increased significantly from 597 cases in 2008 to 2203 cases in 2019 (P < .001). Incidence of biceps tendon tenotomy significantly decreased between the years 2007 and 2018 (P < .001). Both open and arthroscopic biceps tenodesis significantly increased between 2007 and 2018 (P < .001). Most PBT cases were performed simultaneously with other procedures (17,283/17,861; 96.8%). The most common PBT procedure performed overall was open tenodesis of long tendon of biceps (∼60.8%). Complication rates for PBT procedures reported each year did not significantly change between 2007 and 2018 (7.5% vs 9.7%; P = .103). Conclusion: PBT procedures are being increasingly performed among recently trained orthopaedic surgeons. Proximal biceps tenotomy has significantly declined, whereas proximal biceps tenodesis, open or arthroscopic, has significantly increased, demonstrating a possible shift in the standard of care among new surgeons.
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Affiliation(s)
- John W Belk
- Department of Orthopaedics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Steven D Jones
- Department of Orthopaedics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Stephen G Thon
- Department of Orthopaedics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Rachel M Frank
- Department of Orthopaedics, University of Colorado School of Medicine, Aurora, Colorado, USA
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18
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Zabrzynski J, Gagat M, Paczesny L, Grzanka D, Huri G. Correlation between smoking and neovascularization in biceps tendinopathy: a functional preoperative and immunohistochemical study. Ther Adv Chronic Dis 2020; 11:2040622320956418. [PMID: 33101619 PMCID: PMC7549321 DOI: 10.1177/2040622320956418] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 08/10/2020] [Indexed: 12/31/2022] Open
Abstract
Aims The purpose of this study was to investigate whether smoking is associated with neovascularization in the tendinopathy of the long head of the biceps tendon (LHBT). Methods The study included 40 consecutive patients who underwent arthroscopic biceps tenotomy/tenodesis due to chronic biceps tendinopathy and divided into three groups: (1) non-smokers, (2) former smokers, (3) smokers. LHBT tissue samples were stained with H&E, Alcian blue and Trichrome staining. Immunohistochemical examination was performed using anti-CD31 and anti-CD34. The neovessel density score (NDS) was scored by Bonar criteria. Results The mean period of smoking was 15.50 years with an average number of 24 cigarettes/day in the former smokers and 21.69 years with an average number of 15 cigarettes/day in the active smokers. The mean NDS was 2.23/3 in non-smokers, whereas it was 1.60/3 in former smokers and 1.31/3 in active smokers. The mean American Shoulder and Elbow Surgeons score equaled 46 in never smoked patients, 43.60 in former smokers, and 41.46 in active smokers. In the patients with smoking history, the disorganized tendinous tissue islands were avascular and composed of compact acidic polysaccharides and mucopolysaccharides. We observed negative correlation between the NDS and the smoking indexes, including cigarettes per day (p = 0.0150), smoking years (p = 0.0140), pack-years (p = 0.0088). Conclusion In conclusion, the present study revealed that smoking impairs the vascularization of the biceps tendon in chronic tendinopathy. Clinically, we observed a negative correlation between smoking and neovascularization. Furthermore, there was no correlation between neovascularization and functional preoperative status.
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Affiliation(s)
- Jan Zabrzynski
- Department of Orthopedics, Orvit Clinic, Citomed Healthcare Center, Torun, Poland
| | - Maciej Gagat
- Department of Histology and Embryology, Faculty of Medicine, Nicolaus Copernicus University in Torun, Collegium Medicum in Bydgoszcz, Torun, Poland
| | - Lukasz Paczesny
- Department of Orthopedics, Orvit Clinic, Citomed Healthcare Center, Torun, Poland
| | - Dariusz Grzanka
- Department of Pathology, Faculty of Medicine, Nicolaus Copernicus University in Torun, Collegium Medicum in Bydgoszcz, Torun, Poland
| | - Gazi Huri
- Orthopedics and Traumatology Department, Hacettepe Universitesi, Ankara, Turkey
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19
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Abstract
BACKGROUND Distal biceps tendon injuries typically occur in the dominant arm of men in their fourth decade of life. Surgical repair restores flexion and supination strength, resulting in good functional outcome. The complication profile of each surgical approach and fixation technique has not been widely studied in the literature. PURPOSE To report the rate of complications after repair of complete distal biceps ruptures, to classify them according to surgical approach and fixation technique, and to analyze risk factors and outcomes of the individual complications. STUDY DESIGN Systematic review. METHODS Studies published in English on primary repair of the distal biceps between January 1998 and January 2019 were identified. Data on complications were extracted and classified as major and minor for analysis. A quantitative synthesis of data was done to compare the complication rates between (1) limited anterior incision, extensile anterior incision, and double incision and (2) 4 fixation methods. RESULTS Seventy-two articles including 3091 primary distal biceps repairs were identified. The overall complication rate was 25% (n = 774). The major complication rate was 4.6% (n = 144) and included a 1.6% (n = 51) rate of posterior interosseous nerve injury; 0.3% (n = 10), median nerve injury; 1.4% (n = 43), rerupture; and a 0.1% (n = 4), synostosis. Brachial artery injury, ulnar nerve injury, compartment syndrome, proximal radius fracture, and chronic regional pain syndrome occurred at a rate of <0.1% each. The majority of nerve injuries resolved with an expectant approach. The minor complication rate was 20.4% (n = 630). The most common complication was lateral cutaneous nerve injury (9.2%, n = 283). An extensile single incision was associated with a higher rate of superficial radial nerve injury when compared to limited single incision(6% vs 2.1%, P = .002). Limited anterior single incision technique had a higher rate of lateral antebrachial cutaneous nerve injury compared to extensile single incision. (9.7% vs 5.2%, P = .03). Synostosis occurred only with double incision. Fixation technique had no significant effect on rerupture rate and posterior interosseous nerve injury rate. CONCLUSION This is the largest analysis of complications after distal biceps repair, indicating a major complication rate of 4.6%. This study provides valuable data with regard to the choice of technique, surgical approach, and rate of complications, which is essential for surgical planning and patient consent. REGISTRATION CRD42017074066 (PROSPERO).
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Affiliation(s)
- Melanie Amarasooriya
- Base Hospital Diyatalawa, Diyatalawa, Sri Lanka.,University of Colombo, Colombo, Sri Lanka
| | - Gregory Ian Bain
- Department of Orthopaedic and Trauma Surgery, Flinders University and Flinders Medical Centre, Adelaide, Australia
| | - Tom Roper
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Kimberley Bryant
- Department of Orthopaedic and Trauma Surgery, Flinders University, Adelaide, Australia
| | - Karim Iqbal
- Trauma and Orthopaedics, Brighton and Sussex University Hospitals, Brighton, UK
| | - Joideep Phadnis
- Brighton and Sussex University Hospitals and Brighton & Sussex Medical School, Brighton, UK
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20
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van Deurzen DFP, Garssen FL, Kerkhoffs GMMJ, Bleys RLAW, Ten Have I, van den Bekerom MPJ. Clinical relevance of the anatomy of the long head bicipital groove, an evidence-based review. Clin Anat 2020; 34:199-208. [PMID: 32379369 DOI: 10.1002/ca.23610] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 03/31/2020] [Accepted: 04/18/2020] [Indexed: 11/09/2022]
Abstract
Pathology in the bicipital groove can be a source of anterior shoulder pain. Many studies have compared treatment techniques for the long head biceps tendon (LHBT) without showing any clinically significant differences. As the LHBT is closely related to the bicipital groove, anatomical aspects of this groove could also be implicated in surgical outcomes. The aim of this review is to contribute to developing the optimal surgical treatment of LHBT pathology based on clinically relevant aspects of the bicipital groove. Medline/PubMed was systematically searched using key words "bicipital" and "groove" and combinations of their synonyms. Studies reporting on evolution, embryonic development, morphometry, vascularization, innervation, and surgical treatment of the LHBT and the bicipital groove were included. The length of the bicipital groove reported in the included studies ranged from 81.00 mm to 87.33 mm, width from 7.74 mm to 11.60 mm, and depth from 3.70 mm to 6.00 mm. The anatomy of the bicipital groove shows a bottleneck narrowing approximately two-thirds from superior. The transverse humeral ligament can constrain the bicipital groove and could be involved in anterior shoulder pain. When either LHBT tenotomy or tenodesis is performed, routinely releasing the transverse ligament could decrease postoperative anterior shoulder pain, which has frequently been reported in the literature. To avoid the bottle neck narrowing, a location below the bicipital groove may be preferred for biceps tenodesis over a more proximal tenodesis site. Level of evidence: IV.
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Affiliation(s)
- Derek F P van Deurzen
- Shoulder and Elbow Unit, Department of Orthopedic Surgery, OLVG, Amsterdam, The Netherlands
| | - Frans L Garssen
- Shoulder and Elbow Unit, Department of Orthopedic Surgery, OLVG, Amsterdam, The Netherlands
| | - Gino M M J Kerkhoffs
- Department of Orthopedic Surgery, Amsterdam Movement Sciences (AMS), Amsterdam University Medical Center (AUMC), Amsterdam Centre for European Studies (ACES) and the Amsterdam Collaboration on Health and Safety in Sports (ACHSS), Amsterdam, The Netherlands
| | - Ronald L A W Bleys
- Department of Anatomy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Isha Ten Have
- Shoulder and Elbow Unit, Department of Orthopedic Surgery, OLVG, Amsterdam, The Netherlands
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21
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Anil U, Hurley ET, Kingery MT, Pauzenberger L, Mullett H, Strauss EJ. Surgical treatment for long head of the biceps tendinopathy: a network meta-analysis. J Shoulder Elbow Surg 2020; 29:1289-1295. [PMID: 32037231 DOI: 10.1016/j.jse.2019.10.021] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 10/19/2019] [Accepted: 10/27/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Surgical options for pathology affecting the long head of the biceps tendon (LHBT) include tenotomy and tenodesis, both of which can be performed with a variety of fixation methods. This study aimed to compare surgical treatment options for LHBT lesions using a network meta-analysis of published clinical studies. METHODS A systematic review of the literature was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Clinical studies comparing surgical treatment options for LHBT lesions were included. Postoperative outcomes were compared between surgical treatment options using a frequentist approach to network meta-analysis. RESULTS There were 22 studies comparing surgical treatment options for LHBT pathology including arthroscopic tenotomy, arthroscopic suprapectoral tenodesis, arthroscopic intracuff tenodesis, and open subpectoral tenodesis, consisting of 1804 patients. Compared with arthroscopic tenotomy, open subpectoral tenodesis resulted in a significantly greater American Shoulder and Elbow Surgeons score (mean difference, 4.58; P = .014). On the basis of the P-score, all 3 tenodesis techniques ranked above tenotomy with respect to the Constant score. Compared with arthroscopic tenotomy, the incidence of Popeye deformity was reduced with arthroscopic suprapectoral tenodesis (odds ratio [OR], 0.23; P < .001) and open subpectoral tenodesis (OR, 0.25; P = .022). The incidence of bicipital groove pain was increased after arthroscopic intracuff tenodesis (OR, 2.89; P = .021) compared with arthroscopic tenotomy. CONCLUSION Lesions of the LHBT treated with open or arthroscopic tenodesis resulted in comparatively superior functional outcomes and a lower incidence of Popeye deformity, whereas arthroscopic intracuff tenodesis resulted in a higher incidence of bicipital groove pain.
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Affiliation(s)
- Utkarsh Anil
- Division of Sports Medicine, Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| | - Eoghan T Hurley
- Department of Trauma and Orthopaedics, Royal College of Surgeons in Ireland, Dublin, Ireland; Sports Surgery Clinic, Dublin, Ireland
| | - Matthew T Kingery
- Division of Sports Medicine, Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| | | | | | - Eric J Strauss
- Division of Sports Medicine, Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA.
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22
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Schiefer M, Cossich V, Siqueira G, Monteiro MT, Nery LF, Motta G. Intra-articular arthroscopic biceps tenodesis with interference screw: clinical and isokinetic evaluation. JSES Int 2020; 4:632-637. [PMID: 32939498 PMCID: PMC7479042 DOI: 10.1016/j.jseint.2020.03.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Background Although biceps tenodesis has been widely used to treat its pathologies, few studies looked at the objective evaluation of elbow strength after this procedure. The purpose of this study is to clinically evaluate patients submitted to long head of the biceps (LHB) tenodesis with interference screws through an intra-articular approach and analyze the results of an isokinetic test to measure elbow flexion and forearm supination strengths. Methods Patients who had biceps tenodesis were included in the study if they had a minimum follow-up of 24 months. Patients were excluded if they had concomitant irreparable cuff tears or previous or current contralateral shoulder pain or weakness. Postoperative evaluation was based on University of California-Los Angeles (UCLA) shoulder score and on measurements of elbow flexion and supination strength, using an isokinetic dynamometer. Tests were conducted in both arms, with velocity set at 60º/s with 5 concentric-concentric repetitions. Results Thirty-three patients were included and the most common concomitant diagnosis were rotator cuff tear (69%) and superior labrum anterior to posterior (SLAP) lesions (28%). The average UCLA score improved from 15.1 preoperatively to 31.9 in the final follow-up (P < .001). Isokinetic tests showed no difference in peak torque between the upper limbs. One patient had residual pain in the biceps groove. None of the patients had Popeye deformity. UCLA score and follow-up length did not demonstrate correlation with peak torque. Conclusion Arthroscopic proximal biceps tenodesis with interference screw, close to the articular margin, yielded good clinical results. Isokinetic tests revealed no difference to the contralateral side in peak torque for both supination and elbow flexion.
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Affiliation(s)
- Márcio Schiefer
- Department of Orthopaedics, Medicine School, Rio de Janeiro Federal University, Rio de Janeiro, Brazil
| | - Victor Cossich
- Neuromuscular Research Laboratory, National Institute of Trauma and Orthopedics, Rio de Janeiro, Brazil.,Biomechanics Laboratory, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Gláucio Siqueira
- Department of Orthopaedics, National Institute of Trauma and Orthopedics, Rio de Janeiro, Brazil
| | - Martim Teixeira Monteiro
- Department of Orthopaedics, National Institute of Trauma and Orthopedics, Rio de Janeiro, Brazil
| | - Luiz Felipe Nery
- Department of Orthopaedics, National Institute of Trauma and Orthopedics, Rio de Janeiro, Brazil
| | - Geraldo Motta
- Department of Orthopaedics, National Institute of Trauma and Orthopedics, Rio de Janeiro, Brazil
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23
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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24
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Geannette C, Williams D, Berkowitz J, Miller TT. Ultrasound-Guided Biceps Tendon Sheath Injection: Spectrum of Preprocedure Appearances. J Ultrasound Med 2019; 38:3267-3271. [PMID: 31187487 DOI: 10.1002/jum.15062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 05/30/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVES To determine the frequency of ultrasound (US) appearances of the extra-articular long head of the proximal biceps tendon in patients referred for US-guided biceps tendon sheath injections. METHODS We reviewed our US-guided biceps tendon sheath injections between January 2015 and December 2017, noting the appearance of the biceps tendon and sheath, as well as the needle size used, and what was injected. Clinical electronic medical records were also reviewed to determine safety and patients' responses. RESULTS A total of 300 US-guided biceps tendon sheath injections were performed for anterior shoulder pain. Preliminary US evaluations revealed that 129 of 300 (43%) patients had a normal US appearance of the biceps tendon; 110 (36.6%) had tendinosis; 13 (4.3%) had tenosynovitis; 31 (10.3%) had both tendinosis and tenosynovitis; 8 (2.7%) had a biceps tendon tear; and 9 (3%) had a history of a tenodesis. Of 81 patients who had pain relief after the injection, 41 had a normal tendon appearance on US, and 40 had an abnormal US appearance. CONCLUSIONS A large minority of patients with anterior shoulder pain clinically suspected to be due to the biceps tendon have a normal-appearing tendon and sheath. This should not dissuade the operator from performing the procedure.
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Affiliation(s)
- Christian Geannette
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, New York, USA
| | - Danielle Williams
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, New York, USA
| | - Jennifer Berkowitz
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, New York, USA
| | - Theodore T Miller
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, New York, USA
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25
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Bélanger V, Dupuis F, Leblond J, Roy JS. Accuracy of examination of the long head of the biceps tendon in the clinical setting: A systematic review. J Rehabil Med 2019; 51:479-491. [PMID: 31243466 DOI: 10.2340/16501977-2563] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To determine the diagnostic validity of high-resolution ultrasound and orthopaedic special tests in diagnosing long head of the biceps tendon pathologies in patients with shoulder pain. DESIGN Systematic review with meta-analysis tools. DATA SOURCES MEDLINE, CINAHL and EMBASE. DATA EXTRACTION Included studies had to report on the diagnostic validity of orthopaedic special tests or high-resolution ultrasound (HRUS) compared with a reference standard for diagnosing long head of the biceps tendon target conditions (superior labrum anterior and posterior lesions, long head of the biceps tendon tendinopathy, dislocation, effusion or rupture). Risk of bias was assessed using the Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2) tool. RESULTS Of the 30 included studies, 8 focused on high-resolution ultrasound and 22 on orthopaedic special tests. High-resolution ultrasound proved highly specific for the diagnosis of long head of the biceps tendon pathologies. Pooled positive (LR+) and negative (LR-) likelihood ratios were 38.00 and 0.24 for dislocation, respectively, and 35.50 and 0.30 for complete rupture, respectively. The accuracy of orthopaedic special tests varied greatly across studies. The only test of value was Yergason's ma-noeuvre in confirming proximal long head of the biceps tendon pathologies except superior labrum anterior and posterior lesion (high specificity): the summary LR+ and LR- were 2.56 and 0.70, respectively. CONCLUSION High-resolution ultrasound is reliable to confirm suspected long head of the biceps tendon pathologies. There is insufficient evidence to recommend individual orthopaedic special tests.
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Affiliation(s)
- Valérie Bélanger
- Physical medicine and Rehabilitation, CHU de Quebec-Université Lava, G1J1Z4 Quebec City, Canada.
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26
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Zabrzyński J, Szukalski J, Paczesny Ł, Szwedowski D, Grzanka D. Cigarette smoking intensifies tendinopathy of the LHBT. A microscopic study after arthroscopic treatment. POL J PATHOL 2019; 70:134-8. [PMID: 31556564 DOI: 10.5114/pjp.2019.87104] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Smoking has a damaging effect on the musculoskeletal system, which was presented by authors in the rotator cuff and Achilles tendons studies; however, there are a lack of data about the effect of smoking on disorders of the long head of the biceps tendon (LHBT), particularly at the microscopic level. The purpose of this study was to investigate the effect of the tobacco smoking on the histopathologic alterations of the LHBT. Thirty-six patients with preoperatively diagnosed tendinopathy of the LHBT were referred to the Orthopaedics Department. All patients underwent arthroscopic treatment with further macroscopic and microscopic evaluation of biceps tendon samples. The active and former smokers were characterised by more advanced degenerative process of the tendinous tissue; moreover, it was intensified in the group of former smokers. Subjects who smoke more than 20 cigarettes per day also had more advanced microscopic alterations. The most severe microscopic alterations occurred in the former smokers who used tobacco for more than 20 years. However, the non-smokers group revealed moderate degeneration in all LHBT samples. Tobacco smoking is an important risk factor of the LHBT disease, which essentially intensifies the degeneration of the tendinous tissue.
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27
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Tebaa E, Tantot J, Isaac-Pinet S, Nové-Josserand L. Histologic characteristics of the subscapularis tendon from muscle to bone: reference to subscapularis lesions. J Shoulder Elbow Surg 2019; 28:959-65. [PMID: 30711396 DOI: 10.1016/j.jse.2018.11.045] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 11/06/2018] [Accepted: 11/09/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Although subscapularis tendon lesions seem to differ from those of the supraspinatus tendon, the features they have in common suggest that the subscapularis tendon may also have 2 distinct layers. Our aim was therefore to characterize the histologic structure of the subscapularis tendon from its humeral insertion point to the musculotendinous junction. MATERIAL AND METHODS A histologic study was performed on 10 autopsy samples. The subscapularis tendon was extracted in one piece from the musculotendinous junction to the humeral insertion point and was prepared using standard (hematoxylin-eosin-saffron) staining. RESULTS Histologic analysis revealed 2 fibrous layers, distinguishable by the orientation of the collagen bundles. The deep layer was thinner and composed of parallel longitudinal collagen fibers inserting onto the lesser tuberosity flush with the cartilage. The superficial layer was thicker and composed of interdigitated collagen bundles inserting onto the lesser and the greater tuberosity after splitting into 2 bands, 1 lining the floor of the bicipital groove, and the other extending over the long head of the biceps tendon across the groove. Each layer formed an independent musculotendinous junction in the subscapularis muscle. CONCLUSIONS The subscapularis tendon is composed of 2 distinct fibrous layers, just like the supraspinatus tendon, but arranged differently. The superficial layer of the subscapularis tendon passes across the bicipital groove and forms a fibrous ring around the long head of the biceps tendon that stabilizes the latter in the bicipital groove. These results explain some of the specific features of subscapularis tears described in the literature, namely, delamination and biceps subluxation.
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28
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Fawi HM, Dojcinov S, Lyons K, Matthews TJ. Trauma or tumour: giant cell tumour of distal biceps tendon sheath, an unusual cause of elbow pain. Shoulder Elbow 2019; 11:137-139. [PMID: 30936953 PMCID: PMC6434961 DOI: 10.1177/1758573217701064] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 01/28/2017] [Accepted: 02/08/2017] [Indexed: 11/16/2022]
Abstract
We report the case of a middle-age lady who presented following minor trauma, with dominant-sided anterior elbow pain and swelling of 6 months in duration. She was assessed clinically, and underwent investigations, which confirmed features consistent with giant cell tumour (GCT) of distal biceps tendon sheath. She underwent uneventful en-bloc excisional surgery. She did not have radiotherapy. She is now 5 years postoperatively asymptomatic, with full function, and with no signs of recurrence.
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Affiliation(s)
- Hassan M.T. Fawi
- Department of Trauma and Orthopaedics, Cardiff and Vale University Health Board, Cardiff, UK,Hassan MT Fawi, Department of Trauma and Orthopaedics, Cardiff and Vale University Health Board, Heath Park, Cardiff, CF14 4XW, UK.
| | - Stefan Dojcinov
- Department of Cellular Pathology, Cardiff and Vale University Health Board, Cardiff, UK
| | - Kathleen Lyons
- Department of Clinical Radiology, Cardiff and Vale University Health Board, Cardiff, UK
| | - Timothy J.W. Matthews
- Department of Trauma and Orthopaedics, Cardiff and Vale University Health Board, Cardiff, UK
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29
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Douglas L, Whitaker J, Nyland J, Smith P, Chillemi F, Ostrander R, Andrews J. Return to Play and Performance Perceptions of Baseball Players After Isolated SLAP Tear Repair. Orthop J Sports Med 2019; 7:2325967119829486. [PMID: 30873424 PMCID: PMC6407163 DOI: 10.1177/2325967119829486] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Background: Variable return-to-play (RTP) rates have been reported after surgical repair of superior labral anterior-posterior (SLAP) tears in baseball players. Many studies, however, have not controlled for concomitant shoulder injuries. Purpose/Hypothesis: The purpose of this study was to evaluate rates of RTP and return to previous or higher performance level (RTPP) and long-term outcomes after isolated SLAP tear repair. The hypothesis was that improved outcomes would be identified compared with previous reports. Study Design: Case series; Level of evidence, 4. Methods: The records of 232 players who underwent isolated SLAP tear repair from 2004 to 2014 were reviewed. A total of 98 players who were at least 12 months out from surgery were identified. Through telephone interviews, participants completed the Western Ontario Shoulder Instability Index (WOSI) and Veterans RAND 12-Item Health Survey (VR-12) and answered scripted questions about RTP, RTPP, and current symptoms. Results: Of the 98 players who met the inclusion criteria, 73 (74.5%) participated. The mean age at the time of surgery was 19.8 ± 2.9 years. The mean follow-up time was 86.2 ± 25.1 months overall; it was 84.4 ± 24.4 months for pitchers and 90.3 ± 26.7 months for other position players, (P = .40). There were 10 professional, 36 collegiate, and 27 high school players. Most players perceived successful RTP (83.6%), including 80.0% of pitchers and 91.3% of other position players (P = .23). However, RTPP rates were lower, at 52.3% (n = 26) and 78.3% (n = 18) for pitchers and other position players, respectively (P = .03). Pitchers were younger at the time of surgery (19.3 ± 3.0 vs 20.8 ± 3.0 years, respectively; P = .03) and had greater perceived shoulder and general health impairments compared with other position players (P ≤ .02). Players who perceived successful RTPP had better WOSI of the healthy shoulder and individual physical, sports, lifestyle, and emotion scores compared with players who did not perceive successful RTPP. Conclusion: After the surgical repair of isolated type II or greater SLAP tears, other position players displayed superior RTP (91.3% vs 80.0%, respectively) and RTPP (78.3% vs 52.3%, respectively) rates than pitchers. Long-term follow-up suggests that pitchers may perceive greater long-term impairments than other position players and are less likely to return to their previous or higher performance level.
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Affiliation(s)
- Lonnie Douglas
- Division of Sports Medicine, Department of Orthopaedic Surgery, University of Louisville, Louisville, Kentucky, USA.,Andrews Institute for Orthopaedics & Sports Medicine, Gulf Breeze, Florida, USA
| | - John Whitaker
- Division of Sports Medicine, Department of Orthopaedic Surgery, University of Louisville, Louisville, Kentucky, USA
| | - John Nyland
- Division of Sports Medicine, Department of Orthopaedic Surgery, University of Louisville, Louisville, Kentucky, USA
| | - Patrick Smith
- Andrews Institute for Orthopaedics & Sports Medicine, Gulf Breeze, Florida, USA
| | - Filippo Chillemi
- Andrews Institute for Orthopaedics & Sports Medicine, Gulf Breeze, Florida, USA
| | - Roger Ostrander
- Andrews Institute for Orthopaedics & Sports Medicine, Gulf Breeze, Florida, USA
| | - James Andrews
- Andrews Institute for Orthopaedics & Sports Medicine, Gulf Breeze, Florida, USA
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30
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Affiliation(s)
- Khang H Dang
- Department of Orthopaedics, UT Health San Antonio, San Antonio, Texas, USA
| | - Anil K Dutta
- Department of Orthopaedics, UT Health San Antonio, San Antonio, Texas, USA
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31
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Cutler HS, Tao MA, O'Brien SJ, Taylor SA. Trifurcate Origin of Long Head of Biceps Brachii: A Case Report and Literature Review. J Orthop Case Rep 2019; 8:70-73. [PMID: 30687668 PMCID: PMC6343571 DOI: 10.13107/jocr.2250-0685.1166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction Variant anatomy of the intra-articular portion of the long head of the biceps tendon (LHBT) is rare, and its clinical significance is poorly understood. However, these variants are encountered with increasing frequency due to increasing use of shoulder arthroscopy. Case Report We report a case of a trifurcate intra-articular LHBT, a variation which, to our knowledge, has not been previously described. The patient was an adult male presenting with chronic atraumatic shoulder pain that worsened with overhead activity. On arthroscopy, the LHBT was found to have three origins from the (1) supraspinatus tendon, (2) superior labrum, and (3) rotator interval that joined together distally within the biceps tunnel. We believe the split tendon may have caused impingement the biceps tunnel; therefore, the patient was treated with subpectoral tenodesis. He also underwent subacromial decompression and rotator cuff debridement. Conclusion This case highlights the importance of surgeon and radiologist awareness of split LHBT variant anatomy, such that misdiagnosis and unnecessary treatment may be avoided.
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Affiliation(s)
- Holt S Cutler
- Department of Orthopaedic Surgery, UT Southwestern Medical Center, 5200 Harry Hines Boulevard, Dallas, 75235, Texas, USA
| | - Matthew A Tao
- Department of Orthopaedic Surgery, the Sports Medicine and Shoulder Service, Hospital for Special Surgery, 535 East 70th Street, New York, 10021, USA
| | - Stephen J O'Brien
- Department of Orthopaedic Surgery, the Sports Medicine and Shoulder Service, Hospital for Special Surgery, 535 East 70th Street, New York, 10021, USA
| | - Samuel A Taylor
- Department of Orthopaedic Surgery, the Sports Medicine and Shoulder Service, Hospital for Special Surgery, 535 East 70th Street, New York, 10021, USA
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Klebanov N, Wei DH, Harrison BJ, Kimball HL. Optimization of Anterior Incision Placement for Distal Biceps Repair. Cureus 2018; 10:e3141. [PMID: 30345198 PMCID: PMC6188161 DOI: 10.7759/cureus.3141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Introduction Damage to the posterior interosseous nerve (PIN) is a known complication when using a cortical button during distal biceps tendon repair. Prior studies show that the trajectory of the drill through the biceps tuberosity can affect the distance from the PIN. We develop a mathematical model to predict the location of the tuberosity based on a palpable bony landmark and patient demographic factors. Methods The medical charts and elbow radiographs of (n = 82) adult patients were retrospectively reviewed. Using standard radiographic software, two observers measured the distance from the olecranon tip to the center of the biceps tuberosity. Multivariate regression analysis was used to build a linear model. The model was cross-validated with five arms from three distinct cadavers. A surgical wire was guided into the volar aspect of each forearm using the model, and a dissection was then performed to assess the proximity of the surgical wire to the insertion of the biceps tendon on the radial tuberosity. Results Olecranon-tuberosity distance (OTD) ranged from 52.3 mm to 77.2 mm (mean 66.5 mm). Univariate analyses revealed males had significantly longer OTD (mean 69.3 mm) compared to females (mean 61.2 mm, t-test, p < 0.001). Increased body mass index (BMI) weakly correlated with increased distance (Pearson’s r = 0.22, p = 0.048). Height showed strong positive correlation with increased distance (r = 0.77, p < 0.001). Multivariate regression revealed that significant predictive factors for olecranon-tuberosity distance were height (coefficient = 35.8, p < 0.001), BMI (coefficient = 0.14, p = 0.032), and male sex (coefficient = 3.17, p = 0.0039). The average error in the cadaveric validation, measured as distance from the surgical wire to the distal biceps insertion was 1.8 mm. Conclusion A highly accurate mathematical model can be used to predict the location of the biceps tuberosity in relation to the palpable tip of the olecranon, based only on height, BMI, and sex of the patient. Knowledge of this distance can guide accurate placement of the skin incision when a transverse single-incision approach is utilized for repair of the distal biceps tendon using a cortical button. Diagnostics showed the model to be less accurate near the extremes of the measurement. Since patients with a target incision point far removed from average would most benefit from such a model, we will continue by identifying and enrolling patients at the low and high ends of the range. We further hypothesize that the technique described above could be similarly applied to benefit other procedures.
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Affiliation(s)
| | - David H Wei
- Orthopaedic Surgery, Greenwich Hospital, Greenwich, USA
| | - Brendan J Harrison
- Internal Medicine, Steward Carney Hospital/Tufts University School of Medicine, Dorchester, USA
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Zabrzyński J, Paczesny Ł, Zabrzyńska A, Grzanka D, Łapaj Ł. Sonography in the instability of the long head of the biceps tendon confronted with histopathologic and arthroscopic findings. Folia Morphol (Warsz) 2018; 77:583-590. [PMID: 29399753 DOI: 10.5603/fm.a2018.0012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 01/13/2018] [Accepted: 01/16/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Disorders of the long head of the biceps (LHB) tendon are a common source of shoulder pain and disability. This tendon can be well visualised using ultrasonography; however, little is known if such examination allows clinicians to predict pathological changes of the tendon structure. In the study described below, we compare preoperative sonographic findings with the data from shoulder arthroscopy and microscopic examination of the excised tendon fragments in 19 consecutive patients with LHB tendinopathy and clinical suspicion of its instability. MATERIALS AND METHODS Preoperative ultrasonographic (US) inspection assessed several features of the tendon, whereas its stability was verified arthroscopically. In all cases, tenodesis or tenotomy procedures were performed and excised tendon fragments were harvested for microscopic examination based on the semiquantitative Bonar score. RESULTS The most common US findings were hypoechoic areas, tendon thickening, an increased power Doppler signal and mechanical instability. Just as shoulder arthroscopy confirmed all mechanical instability cases detected in US, microscopic assessment revealed advanced degeneration in all samples. CONCLUSIONS Our study indicates that US is a useful tool in identifying cases of advanced instability and LHB tendinopathy, whereas biceps tendon instability is a biomechanically complex, gradually progressing phenomenon, frequently associated with additional shoulder lesions.
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Affiliation(s)
- J Zabrzyński
- Department of Orthopedic Surgery, Multidisciplinary Hospital, Inowrocław, Poland.
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Zabrzyński J, Gagat M, Paczesny Ł, Łapaj Ł, Grzanka D. Electron microscope study of the advanced tendinopathy process of the long head of the biceps brachii tendon treated arthroscopically. Folia Morphol (Warsz) 2018; 77:371-7. [PMID: 29131279 DOI: 10.5603/FM.a2017.0105] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 10/16/2017] [Accepted: 10/19/2017] [Indexed: 12/24/2022]
Abstract
BACKGROUND The ultrastructural alterations related to tendinopathy have not been well described. Most studies on this subject have been conducted many years ago and focused on material from the Achilles tendon. It was demonstrated that various comorbidities can affect ultrastructural alterations in the advanced tendinopathy; however, there is very little data on ultrastructural morphology in tendinopathies related to mechanical overload as in case of the long head of the biceps brachii tendon (LHBT). The aim was to determine intermediate ultrastructural alterations in middle to severe grade the LHBT tendinopathy and to establish if they are different than those reported in the literature for other anatomical locations. MATERIALS AND METHODS In this study we examined the ultrastructure of a series of the LHBT fragments arthroscopically removed due to tendinopathy and inve-stigated the morphology of tenocytes and collagen fibres in cases of the LHBT tendinopathy. RESULTS In pathological samples tenocytes were randomly scattered, their shape was round and the shape of nuclei was also disrupted. The presence of apoptotic--like features in tenocytes' nuclei was noted. All samples showed replacement of collagen fibrils by non-collagen extracellular matrix and diffuse collagen disorganisation. CONCLUSIONS It was demonstrated at ultrastructural level that the LHBT tendino-pathy is not simply a wear and tear phenomenon, since chronic degeneration of the extracellular matrix and tenocytes were present, similarly as in tendinopathies, in other anatomical locations. (Folia Morphol 2018; 77, 2: 371-377).
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Kerschbaum M, Maziak N, Böhm E, Scheibel M. Elbow flexion and forearm supination strength in a healthy population. J Shoulder Elbow Surg 2017; 26:1616-1619. [PMID: 28734715 DOI: 10.1016/j.jse.2017.05.031] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 05/24/2017] [Accepted: 05/27/2017] [Indexed: 02/01/2023]
Abstract
BACKGROUND AND HYPOTHESIS Despite the lack of representative data of a healthy population, many clinical trials concerning the measurement of postoperative elbow flexion or forearm supination strength use the contralateral side as a control. We hypothesized that there are no differences in elbow flexion and supination strength between the dominant and nondominant sides in healthy volunteers. METHODS The study was performed on a cross-sectional cohort of healthy subjects without any prior injuries or surgical interventions of the upper extremities. Isometric elbow flexion strength and supination strength were measured on both the dominant and nondominant sides. The results were analyzed for the entire group and subanalyzed for female vs. male, for different age groups, and according to handedness and regular practice of overhead sports. RESULTS A total of 150 subjects (75 female and 75 male subjects; mean age, 44 ± 15 years [range, 18-72 years]) were included in this study. Within the entire collective, no significant differences concerning the elbow flexion strength between the dominant and nondominant sides could be detected, whereas the supination strength was 7% higher on the dominant side (P = .010). Women, right-hand-dominant subjects, and subjects who do not regularly practice overhead sports have a significant 8% higher supination strength on the dominant side compared with the nondominant side (P < .05). Left-hand-dominant subjects have an 8% higher elbow flexion strength on the nondominant right side (P < .05). CONCLUSION Elbow flexion strength and forearm supination strength differ between the dominant and nondominant sides. The contralateral upper extremity cannot be used as a matched control without some adjustments.
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Affiliation(s)
- Maximilian Kerschbaum
- Center for Musculoskeletal Surgery, Campus-Virchow/Campus-Mitte, Charité-Unversitätsmedizin Berlin, Berlin, Germany
| | - Nina Maziak
- Center for Musculoskeletal Surgery, Campus-Virchow/Campus-Mitte, Charité-Unversitätsmedizin Berlin, Berlin, Germany
| | - Elisabeth Böhm
- Center for Musculoskeletal Surgery, Campus-Virchow/Campus-Mitte, Charité-Unversitätsmedizin Berlin, Berlin, Germany
| | - Markus Scheibel
- Center for Musculoskeletal Surgery, Campus-Virchow/Campus-Mitte, Charité-Unversitätsmedizin Berlin, Berlin, Germany.
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Albright JP. CORR Insights (®) : Anterolateral Ligament of the Knee Shows Variable Anatomy in Pediatric Specimens. Clin Orthop Relat Res 2017; 475:1592-5. [PMID: 28247330 DOI: 10.1007/s11999-016-5214-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 12/14/2016] [Indexed: 01/31/2023]
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Abstract
Background: Biceps tenotomy and tenodesis are frequently performed for proximal biceps lesions; however, there continues to be debate as to which method is superior. This study examined patient-reported outcomes after biceps tenotomy. Hypothesis: Biceps tenotomy in the setting of concomitant shoulder pathology is a reasonable option with high satisfaction rates and a low incidence of pain and cramping in middle-aged to older individuals. Study Design: Case series; Level of evidence, 4. Methods: A total of 104 patients (mean age, 63.5 years; range, 40-81 years) were evaluated at the time of surgery and at a mean follow-up of 38.4 months (range, 22-57 months). Biceps tenotomy was performed as a component of more extensive shoulder surgery in all patients. Patient satisfaction, frequency of cramping and spasms, biceps pain, weakness, and cosmetic deformity were evaluated at over 1-year follow-up. Results: Ninety-one percent of patients were satisfied or very satisfied with their surgical outcome, and 95% would have their surgery again. Three patients who reported being unsatisfied or very unsatisfied had either advanced glenohumeral arthritis or an irreparable rotator cuff tear. Cosmetic deformity occurred in 13% of patients. Twenty percent reported spasms and cramping in their biceps, and 19% reported some biceps pain; however, frequency of spasms and cramping was typically once weekly, and biceps pain was reported as severe or very severe in only 2 patients. Subjective biceps weakness was reported in 17% of patients. Age had no effect on outcome measures, and female sex was associated with less limitation and greater satisfaction after tenotomy compared with men. Conclusion: Our results indicate that patient-reported downsides to biceps tenotomy were usually mild and/or infrequent and did not affect patient satisfaction. We conclude that biceps tenotomy is a viable option that can lead to a high rate of patient satisfaction and outcomes in middle-aged to older individuals undergoing shoulder surgery with biceps pathology.
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Affiliation(s)
- Brett D Meeks
- Department of Orthopaedic Surgery, Wright State University, Dayton, Ohio, USA
| | | | - Andrew W Froehle
- Department of Orthopaedic Surgery, Wright State University, Dayton, Ohio, USA
| | - Emily Wareing
- Jordan-Young Institute, Orthopaedic Surgery and Sports Medicine, Virginia Beach, Virginia, USA
| | - Kevin F Bonner
- Jordan-Young Institute, Orthopaedic Surgery and Sports Medicine, Virginia Beach, Virginia, USA
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Howard DR, Kazemi N, Rubenstein WJ, Hartwell MJ, Poeran J, Chang AL, Podolnick JD, Parsons BO, Galatz LM, Flatow EL. Cost-benefit analysis of routine pathology examination in primary shoulder arthroplasty. J Shoulder Elbow Surg 2017; 26:674-678. [PMID: 28277257 DOI: 10.1016/j.jse.2016.09.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 08/21/2016] [Accepted: 09/07/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND The annual number of shoulder arthroplasty procedures is continuing to increase. Specimens from shoulder arthroplasty cases are routinely sent for pathologic examination. This study sought to evaluate the clinical utility and associated costs of routine pathologic examination of tissue removed during primary shoulder arthroplasty cases and to determine cost-effectiveness of this practice. METHODS This is a retrospective review of primary shoulder arthroplasty cases. Patients whose humeral head was sent for routine pathologic examination were included. Cases were determined to have concordant, discrepant, or discordant diagnoses based on preoperative/postoperative diagnosis and pathology diagnosis. Costs were estimated in 2015 U.S. dollars, and cost-effectiveness was determined by the cost per discrepant diagnosis and cost per discordant diagnosis. RESULTS We identified 714 cases of primary shoulder arthroplasty in 646 patients who met inclusion criteria. The prevalence of concordant diagnoses was 94.1%, the prevalence of discrepant diagnoses was 5.9%, and no cases had discordant diagnoses. There were 172 cases that had biceps tendon specimens sent for pathology examination, and none led to a change in patient care. Total estimated costs were $77,309.34 in 2015 U.S. dollars. Cost per discrepant diagnosis for humeral head specimens was $1424.09, and cost per discordant diagnosis is at least $59,811.78. DISCUSSION/CONCLUSION Primary shoulder arthroplasty has a high rate of concordant diagnosis. Discrepant diagnoses were 5.9% in our study, and there were no discordant diagnoses. This study showed limited clinical utility in routinely sending specimens from primary shoulder arthroplasty cases for pathology examination, and calculation using a traditional life-year value of $50,000 showed that the standard for cost-effectiveness is not met.
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Affiliation(s)
- Daniel R Howard
- Department of Orthopedic Surgery, Mount Sinai St. Luke's-Roosevelt Hospital, New York, NY, USA.
| | - Namdar Kazemi
- Leni & Peter W. May Department of Orthopaedic Surgery, Mount Sinai Health System, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - William J Rubenstein
- Leni & Peter W. May Department of Orthopaedic Surgery, Mount Sinai Health System, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Matthew J Hartwell
- Leni & Peter W. May Department of Orthopaedic Surgery, Mount Sinai Health System, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jashvant Poeran
- Institute for Healthcare Delivery Science, Department of Population Health Science & Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Andy L Chang
- Department of Orthopedic Surgery, Mount Sinai St. Luke's-Roosevelt Hospital, New York, NY, USA
| | - Jeremy D Podolnick
- Department of Orthopedic Surgery, Mount Sinai St. Luke's-Roosevelt Hospital, New York, NY, USA
| | - Bradford O Parsons
- Leni & Peter W. May Department of Orthopaedic Surgery, Mount Sinai Health System, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Leesa M Galatz
- Leni & Peter W. May Department of Orthopaedic Surgery, Mount Sinai Health System, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Evan L Flatow
- Leni & Peter W. May Department of Orthopaedic Surgery, Mount Sinai Health System, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Chalmers PN, Wimmer MA, Verma NN, Cole BJ, Romeo AA, Cvetanovich GL, Pearl ML, Chalmers PN, Wimmer MA, Verma NN, Cole BJ, Romeo AA, Cvetanovich GL, Pearl ML. The Relationship Between Pitching Mechanics and Injury: A Review of Current Concepts. Sports Health 2017; 9:216-221. [PMID: 28107113 PMCID: PMC5435152 DOI: 10.1177/1941738116686545] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Context: The overhand pitch is one of the fastest known human motions and places enormous forces and torques on the upper extremity. Shoulder and elbow pain and injury are common in high-level pitchers. A large body of research has been conducted to understand the pitching motion. Evidence Acquisition: A comprehensive review of the literature was performed to gain a full understanding of all currently available biomechanical and clinical evidence surrounding pitching motion analysis. These motion analysis studies use video motion analysis, electromyography, electromagnetic sensors, and markered motion analysis. This review includes studies performed between 1983 and 2016. Study Design: Clinical review. Level of Evidence: Level 5. Results: The pitching motion is a kinetic chain, in which the force generated by the large muscles of the lower extremity and trunk during the wind-up and stride phases are transferred to the ball through the shoulder and elbow during the cocking and acceleration phases. Numerous kinematic factors have been identified that increase shoulder and elbow torques, which are linked to increased risk for injury. Conclusion: Altered knee flexion at ball release, early trunk rotation, loss of shoulder rotational range of motion, increased elbow flexion at ball release, high pitch velocity, and increased pitcher fatigue may increase shoulder and elbow torques and risk for injury.
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Affiliation(s)
- Peter N. Chalmers
- Peter N. Chalmers, MD, Department of Orthopaedic Surgery, Rush University Medical Center, 1611 West Harrison Street, Chicago, IL 60612 ()
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Petscavage-Thomas J, Gustas C. Comparison of Ultrasound-Guided to Fluoroscopy-Guided Biceps Tendon Sheath Therapeutic Injection. J Ultrasound Med 2016; 35:2217-2221. [PMID: 27582534 DOI: 10.7863/ultra.15.08076] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 01/23/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES Biceps tendinitis is a source of anterior shoulder pain and is amenable to therapeutic injection. Studies have shown greater accuracy with image-guided compared to unguided injection of the biceps tendon sheath. There is no literature comparing ultrasound-guided to fluoroscopy-guided biceps tendon sheath injection. The purpose of this study was to compare clinical outcomes, complication rates, procedure success rates, and financial costs of the two imaging-guided methods. METHODS A 10-year retrospective review of the picture archiving and communication system was performed to identify patients who underwent image-guided proximal biceps tendon sheath injection. Two radiologists reviewed the picture archiving and communication system and clinical notes to record pain relief, complications, fluoroscopy time, first-pass success rate (defined as injection into the sheath on the first needle pass), final success rate (needle placement in the tendon sheath on the final needle pass), and average costs. RESULTS Fifty fluoroscopy-guided and 53 ultrasound-guided cases were identified. There was no statistically significant difference in pain relief or complications. The first-pass success rate was 90.6% for ultrasound compared to 74.0% for fluoroscopy. The final-pass success rate was 98.2% for ultrasound versus 92.0% for fluoroscopy. The mean fluoroscopy time was 57.6 seconds. Ultrasound showed preinjection abnormalities of the biceps tendon in 47.5% of cases. CONCLUSIONS Compared to fluoroscopy-guided biceps tendon sheath injection, ultrasound had higher initial- and final-pass success rates, visualized abnormalities before injection, and had similar pain relief and complication rates. Ultrasound is more accurate and has greater diagnostic benefits than unguided or fluoroscopy-guided biceps tendon sheath injection.
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Affiliation(s)
| | - Cristy Gustas
- Department of Radiology, Penn State Hershey Medical Center, Hershey, Pennsylvania USA
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Cates RA, Steinmann SP, Adams JE. Irreducible anteromedial radial head dislocation caused by the brachialis tendon: a case report. J Shoulder Elbow Surg 2016; 25:e232-5. [PMID: 27422462 DOI: 10.1016/j.jse.2016.04.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 04/12/2016] [Accepted: 04/16/2016] [Indexed: 02/01/2023]
Affiliation(s)
- Robert A Cates
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Julie E Adams
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA.
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Abstract
Background: Various tenodesis methods are being used for long head of the biceps tendon lesions. However, there is no consensus on the most appropriate surgical method. Hypothesis: There are significant differences in incidence of cosmetic deformity and persistent bicipital pain between open subpectoral and arthroscopic intracuff tenodesis groups. Study Design: Cohort study; Level of evidence, 3. Methods: This study included 72 patients who underwent biceps tenodesis and rotator cuff repair between January 2009 and May 2014 and who were followed for at least 1 year. Open subpectoral tenodesis was performed in 39 patients (group A), and arthroscopic intracuff tenodesis was performed in 33 patients (group B). Results: In group A, the mean visual analog scale (VAS) score for pain during motion and mean University of California, Los Angeles (UCLA) and Constant scores significantly improved from 4.6, 18.6, and 64.5 preoperatively to 1.9, 30.5, and 86.5 at last follow-up, respectively (P < .001 for all). In group B, these scores significantly improved from 5.1, 17.6, and 62.9 preoperatively to 1.8, 31.5, and 85.9 at last follow-up, respectively (P < .001 for all). Popeye deformity was noted in 2 (5.2%) patients from group A and 5 (15.6%) patients from group B (P = .231). Additionally, persistent bicipital tenderness was noted in 1 (2.6%) patient from group A and 8 (24.2%) patients from group B (P = .012). Conclusion: Both open subpectoral tenodesis and arthroscopic intracuff tenodesis show good clinical outcomes for long head of the biceps tendon lesions. However, open subpectoral tenodesis may be more appropriate, considering the low incidence of Popeye deformity and tenderness.
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Affiliation(s)
- Ho Yeon Jeong
- Department of Orthopaedic Surgery, Graduate School, Kyung Hee University, Seoul, South Korea
| | - Jung Youn Kim
- Department of Orthopaedic Surgery, Graduate School, Kyung Hee University, Seoul, South Korea
| | - Nam Su Cho
- Department of Orthopaedic Surgery, Shoulder & Elbow Clinic, College of Medicine, Kyung Hee University, Seoul, South Korea
| | - Yong Girl Rhee
- Department of Orthopaedic Surgery, Shoulder & Elbow Clinic, College of Medicine, Kyung Hee University, Seoul, South Korea
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Abstract
Background: Pulling the long head of the biceps tendon into the joint at arthroscopy is a common method for evaluation of tendinopathic lesions. However, the rate of missed diagnoses when using this technique is reported to be as high as 30% to 50%. Hypothesis: Tendon excursion achieved using a standard arthroscopic probe does not allow adequate visualization of extra-articular sites of predilection of tendinopathy. Study Design: Descriptive laboratory study. Methods: Seven forequarter amputation cadaveric specimens were evaluated. The biceps tendon was tagged to mark the intra-articular length and the maximum excursions achieved using a probe and a grasper in both beach-chair and lateral positions. Statistical analyses were performed using analysis of variance to compare means. Results: The mean intra-articular and extra-articular lengths of the tendons were 23.9 and 82.3 mm, respectively. The length of tendon that could be visualized by pulling it into the joint with a probe through the anterior midglenoid portal was not significantly different when using either lateral decubitus (mean ± SD, 29.9 ± 3.89 mm; 95% CI, 25.7-34 mm) or beach-chair positions (32.7 ± 4.23 mm; 95% CI, 28.6-36.8 mm). The maximum length of the overall tendon visualized in any specimen using a standard technique was 37 mm. Although there was a trend to greater excursion using a grasper through the same portal, this was not statistically significant. However, using a grasper through the anterosuperior portal gave a significantly greater mean excursion than any other technique (46.7 ± 4.31 mm; 95% CI, 42.6-50.8 mm), but this still failed to allow evaluation of Denard zone C. Conclusion: Pulling the tendon into the joint with a probe via an anterior portal does not allow visualization of distal sites of predilection of pathology. Surgeons should be aware that this technique is inadequate and can result in missed diagnoses. Clinical Relevance: This study demonstrates that glenohumeral arthroscopy does not allow visualization of common areas of pathology of the long head of the biceps tendon.
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Affiliation(s)
- Adnan Saithna
- The Pam Am Clinic Foundation, Winnipeg, Manitoba, Canada.; Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada.; Southport and Ormskirk Hospitals NHS Trust, Lancashire, UK
| | - Alison Longo
- The Pam Am Clinic Foundation, Winnipeg, Manitoba, Canada
| | - Jeff Leiter
- The Pam Am Clinic Foundation, Winnipeg, Manitoba, Canada.; Southport and Ormskirk Hospitals NHS Trust, Lancashire, UK
| | - Jason Old
- The Pam Am Clinic Foundation, Winnipeg, Manitoba, Canada
| | - Peter M MacDonald
- The Pam Am Clinic Foundation, Winnipeg, Manitoba, Canada.; Southport and Ormskirk Hospitals NHS Trust, Lancashire, UK
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Singh R, Singla M, Tubbs RS. Macro/micro observational studies of fibres maintaining the biceps brachii tendon in the bicipital groove: application to surgery, pathology and kinesiology. Folia Morphol (Warsz) 2015; 74:439-46. [PMID: 26620503 DOI: 10.5603/fm.2015.0105] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Revised: 01/13/2015] [Accepted: 01/18/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND There is controversy over the nature of tissues covering the bicipital groove protecting the biceps brachii tendon from dislocation/subluxation causing shoulder pain. Recent researches on cadaveric dissection and histological studies have changed the old concept of the transverse humeral ligament covering the bicipital groove to tendinous fibres of the subscapularis or interdigitating fibres of the subscapularis and supraspinatus. The change has not been incorporated into standard text books of anatomy. Therefore, the aim of the study is to support the new or old concept. MATERIALS AND METHODS Eighteen embalmed shoulders were dissected to determine the nature of the tissues over the bicipital groove. Tissues from 4 shoulders were processed and 16 histological slides were examined for fibre types. Theoretical analysis of ligament and tendon has also been carried out. RESULTS The dissection study revealed that the tissues over the bicipital groove were tendinous fibres of subscapularis/interdigitating fibres of the subscapularis and supraspinatus and fibrous expansions from the posterior lamina of the pectoralis major. This was supported by the histological slides which showed the signatures of collagen fibres with the characteristics of tendinous fibres. CONCLUSIONS No separate anatomical entity such as the transverse humeral ligament was detected in this study. Thus present study supports the view that the tissues covering the bicipital groove were formed by tendinous rather than ligamentous fibres.
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Affiliation(s)
- R Singh
- Department of Anatomy, AIIMS, Rishikesh Uttrakhand, India.
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Erickson J, Lavery K, Monica J, Gatt C, Dhawan A. Surgical treatment of symptomatic superior labrum anterior-posterior tears in patients older than 40 years: a systematic review. Am J Sports Med 2015; 43:1274-82. [PMID: 24961444 DOI: 10.1177/0363546514536874] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Successful arthroscopic repair of symptomatic superior labral tears in young athletes has been well documented. Superior labral repair in patients older than 40 years is controversial, with concerns for residual postoperative pain, stiffness, and higher rates of revision surgery. PURPOSE To analyze the published data on the surgical treatment of superior labral injuries in patients aged ≥40 years, including those with concomitant injuries to the rotator cuff. STUDY DESIGN Systematic review. METHODS A systematic review of the literature was performed using the Preferred Reporting Items of Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The MEDLINE database via PubMed and the Cochrane Database of Systematic Reviews were searched for articles related to superior labrum anterior-posterior (SLAP) tears. Studies were included if they met the following criteria: the study contained at least 1 group of patients who had undergone arthroscopic repair of a type II or IV SLAP lesion with a minimum 2-year follow-up, objective and/or functional scoring systems were used to evaluate postoperative outcomes, and the mean patient age was ≥40 years for at least 1 treatment arm or subgroup analysis. Studies were excluded if the article was a review or if the article included data for SLAP type I, III, or V to X tears or Bankart lesions. RESULTS While several authors reported equivalent outcomes of SLAP repair in patients both older than 40 years and younger than 40 years, others demonstrated significantly higher failure rates in the older cohort. Decreased patient satisfaction and increasing complications, including postoperative stiffness and reoperations, occur at higher rates as the patient age increases. The literature demonstrates that biceps tenotomy and tenodesis are reliable alternatives to SLAP repair and that biceps tenotomy is a viable revision procedure for failed SLAP repair. With concomitant rotator cuff tears, the evidence favors debridement or biceps tenotomy over SLAP repair. CONCLUSION While studies show that good outcomes can be obtained with SLAP repair in an older cohort of patients, age older than 40 years and workers' compensation status are independent risk factors for increased surgical complications. The cumulative evidence supports labral debridement or biceps tenotomy over labral repair when an associated rotator cuff injury is present.
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Affiliation(s)
- John Erickson
- Department of Orthopaedic Surgery, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey, USA
| | - Kyle Lavery
- Department of Orthopaedic Surgery, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey, USA
| | - James Monica
- Department of Orthopaedic Surgery, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey, USA
| | - Charles Gatt
- Department of Orthopaedic Surgery, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey, USA
| | - Aman Dhawan
- Department of Orthopaedic Surgery, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey, USA
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Taylor SA, Fabricant PD, Bansal M, Khair MM, McLawhorn A, DiCarlo EF, Shorey M, O'Brien SJ. The anatomy and histology of the bicipital tunnel of the shoulder. J Shoulder Elbow Surg 2015; 24:511-9. [PMID: 25457787 DOI: 10.1016/j.jse.2014.09.026] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Revised: 09/07/2014] [Accepted: 09/12/2014] [Indexed: 02/01/2023]
Abstract
BACKGROUND The bicipital tunnel is the extra-articular, fibro-osseous structure that encloses the long head of the biceps tendon. METHODS Twelve cadaveric shoulder specimens underwent in situ casting of the bicipital tunnel with methyl methacrylate cement to demonstrate structural competence (n = 6) and en bloc harvest with gross and histologic evaluation (n = 6). The percentage of empty tunnel was calculated histologically by subtracting the proportion of cross-sectional area of the long head of the biceps tendon from that of the bicipital tunnel for each zone. RESULTS Cement casting demonstrated that the bicipital tunnel was a closed space. Zone 1 extended from the articular margin to the distal margin of the subscapularis tendon. Zone 2 extended from the distal margin of the subscapularis tendon to the proximal margin of the pectoralis major tendon. Zone 3 was the subpectoral region. Zones 1 and 2 were both enclosed by a dense connective tissue sheath and demonstrated the presence of synovium. Zone 3 had significantly greater percentage of empty tunnel than zones 1 and 2 did (P < .01). CONCLUSION The bicipital tunnel is a closed space with 3 distinct zones. Zones 1 and 2 have similar features, including the presence of synovium, but differ from zone 3. A significant bottleneck occurs between zone 2 and zone 3, most likely at the proximal margin of the pectoralis major tendon. The bicipital tunnel is a closed space where space-occupying lesions may produce a bicipital tunnel syndrome. Careful consideration should be given to surgical techniques that decompress both zones 1 and 2 of the bicipital tunnel.
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Affiliation(s)
- Samuel A Taylor
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY, USA.
| | - Peter D Fabricant
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY, USA
| | - Manjula Bansal
- Pathology and Laboratory Medicine, Hospital for Special Surgery, New York, NY, USA
| | - M Michael Khair
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY, USA
| | - Alexander McLawhorn
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY, USA
| | - Edward F DiCarlo
- Pathology and Laboratory Medicine, Hospital for Special Surgery, New York, NY, USA
| | - Mary Shorey
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY, USA
| | - Stephen J O'Brien
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY, USA
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Friedman JL, FitzPatrick JL, Rylander LS, Bennett C, Vidal AF, McCarty EC. Biceps Tenotomy Versus Tenodesis in Active Patients Younger Than 55 Years: Is There a Difference in Strength and Outcomes? Orthop J Sports Med 2015; 3:2325967115570848. [PMID: 26535382 PMCID: PMC4555607 DOI: 10.1177/2325967115570848] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Proximal biceps pathology is a significant factor in shoulder pain. Surgical treatment options include biceps tenotomy and subpectoral biceps tenodesis. Tenotomy is a simple procedure, but it may produce visible deformity, subjective cramping, or loss of supination strength. Tenodesis is a comparatively technical procedure involving a longer recovery, but it has been hypothesized to achieve better outcomes in younger active patients (<55 years). HYPOTHESIS This study investigated the outcomes of younger patients who underwent either a biceps tenotomy or tenodesis as part of treatment for shoulder pain. The hypothesis was that, apart from cosmetic deformity, there will be no difference in outcome between the 2 treatment options. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Isometric strength and endurance testing of operative and nonoperative shoulders for forearm supination (FS) and elbow flexion (EF) were tested utilizing an isometric dynamometer. Objective physical assessment was also performed. Subjective outcomes using the modified American Shoulder and Elbow Surgeons score (ASES); Disability of the Arm, Shoulder, and Hand (DASH); visual analog scale (VAS); and perceived biceps symptoms were collected. RESULTS A total of 42 patients (22 tenotomy, 20 tenodesis) with an average follow-up of 3.3 years were studied. The average age at follow-up was 49.9 years. Thirty-five percent (7/20) of tenotomy patients exhibited a "Popeye" deformity, compared with 18.2% (4/22) of tenodesis patients. Strength prior to fatiguing exercise was similar between tenodesis and tenotomy for FS (6.9 vs 7.3 lbs; P < .05), EF in neutral (35.4 vs 35.4 lbs), and EF in supination (33.8 vs 34.2 lbs). Strength was not significantly different between groups for isometric strength and endurance measures. Subjective functional outcome measured by the DASH, ASES, and VAS scores were similar between groups. Frequency of complaints of cramping was higher in the tenotomy group (4/20 vs 1/22), and complaints of pain were higher in the tenodesis group (11/22 vs 5/20). CONCLUSION Despite increased demands and activity placed on biceps function in a younger population, this study showed no differences in functional and subjective outcome measurements. The choice between biceps tenotomy and tenodesis for pathology of the proximal biceps tendon can continue to be based on surgeon and patient preference.
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Affiliation(s)
- Jamie L Friedman
- University of Connecticut Health Center, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | | | - Lucas S Rylander
- Denver VA Medical Center, University of Colorado School of Medicine, Denver, Colorado, USA
| | - Christine Bennett
- CU Sports Medicine, University of Colorado School of Medicine, Boulder, Colorado, USA
| | - Armando F Vidal
- CU Sports Medicine, University of Colorado School of Medicine, Boulder, Colorado, USA
| | - Eric C McCarty
- CU Sports Medicine, University of Colorado School of Medicine, Boulder, Colorado, USA
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Moon SC, Cho NS, Rhee YG. Analysis of "hidden lesions" of the extra-articular biceps after subpectoral biceps tenodesis: the subpectoral portion as the optimal tenodesis site. Am J Sports Med 2015; 43:63-8. [PMID: 25359700 DOI: 10.1177/0363546514554193] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Seong Cheol Moon
- Shoulder & Elbow Clinic, Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, Seoul, Korea
| | - Nam Su Cho
- Shoulder & Elbow Clinic, Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, Seoul, Korea
| | - Yong Girl Rhee
- Shoulder & Elbow Clinic, Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, Seoul, Korea
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Euler SA, Smith SD, Williams BT, Dornan GJ, Millett PJ, Wijdicks CA. Biomechanical analysis of subpectoral biceps tenodesis: effect of screw malpositioning on proximal humeral strength. Am J Sports Med 2015; 43:69-74. [PMID: 25371439 DOI: 10.1177/0363546514554563] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Humeral fracture after subpectoral tenodesis of the long head of biceps tendon (LHB) is a rare but devastating complication. PURPOSE To determine whether malpositioned (laterally eccentric) tenodesis screw placement has an influence on humerus strength reduction compared with central placement. STUDY DESIGN Controlled laboratory study. METHODS Two groups, each consisting of 10 matched pairs of human humeri, were used for this study. Biceps tendons were fixed subpectorally with 8-mm screws in unicortical 8-mm sockets. In the first group, the socket was placed concentrically in the bicipital groove and the tendon was fixed with an interference screw. In the second group, the socket was malpositioned 30% eccentrically to the lateral (tension) side of the humerus. Contralateral humeri remained intact as positive controls. Specimens were aligned in 40° of abduction, and a uniaxial compressive force was applied to the humeral head until failure. Strength reduction was reported as percentage reduction in ultimate failure load between paired humeri. Relative defect size was calculated as a percentage of the total humeral width at the height of the tenodesis. RESULTS Laterally eccentric malpositioned biceps tenodeses significantly decreased humeral strength compared with intact (mean change, -25%; SD, 23%; P=.017), while concentrically placed biceps tenodeses did not (mean change, -10%; SD, 15%; P=.059). A linear regression between relative defect size and strength reduction in the malpositioned group showed a significant negative linear correlation (beta=-2.577; R2=0.423; P=.042). CONCLUSION Humeral fracture after subpectoral tenodesis of the LHB is a complication that may be minimized with careful surgical technique. Laterally eccentric malpositioned biceps tenodesis caused significant reduction (25%) in humeral strength, which might be clinically relevant and contribute to postsurgical humeral shaft fracture. Strength reduction was also significantly correlated with relative defect size. Surgeons using this technique should ensure central and orthogonal placement of the socket, especially in smaller individuals. This study lends biomechanical evidence to support the clinical procedure of a correctly, concentrically placed tenodesis screw. CLINICAL RELEVANCE These biomechanical results indicate that in a clinical setting, special attention should be drawn to patient selection for LHB tenodesis. This study reveals that central screw positioning is critical, particularly in high-impact and overhead athletes, as well as for patients with small humeral widths or osteoporotic bone quality. Alternative surgical options such as smaller screws or other fixation methods might be considered to diminish the postoperative risk of humeral fracture.
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Affiliation(s)
- Simon A Euler
- Steadman Philippon Research Institute, Vail, Colorado, USA Department of Trauma Surgery and Sports Traumatology, Medical University Innsbruck, Innsbruck, Austria
| | - Sean D Smith
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | | | - Grant J Dornan
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Peter J Millett
- Steadman Philippon Research Institute, Vail, Colorado, USA The Steadman Clinic, Vail, Colorado, USA
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