Diagnostic accuracy in detecting tears in the proximal biceps tendon using standard nonenhancing shoulder MRI

BACKGROUND

There is a paucity of data in the literature evaluating the performance of noncontrast MRI in the diagnosis of partial and complete tears of the proximal portion of the long head of the biceps (LHB) tendon. The objective of this study was to evaluate the accuracy of noncontrast magnetic resonance imaging (MRI) compared to arthroscopy for the diagnosis of pathology involving the intra-articular portion of the LHB tendon.

METHODS

We conducted a retrospective review of 66 patients (mean age 57.8 years, range 43-70 years) who underwent shoulder arthroscopy and evaluation of the LHB tendon after having had a noncontrast MRI of the shoulder. Biceps pathology was classified by both MRI and direct arthroscopic visualization as either normal, partial tearing, or complete rupture, and arthroscopy was considered to be the gold standard. We then determined the sensitivity, specificity, and positive- and negative-predictive values of MRI for the detection of partial and complete LHB tears.

RESULTS

MRI identified 29/66 (43.9%) of patients as having a pathologic lesion of the LHB tendon (19 partial and ten complete tears) while diagnostic arthroscopy identified tears in 59/66 patients (89.4%; 50 partial and 16 complete). The sensitivity and specificity of MRI for detecting partial tearing of the LHB were 27.7% and 84.2%, respectively (positive predictive value =81.2%, negative predictive value =32.0%). The sensitivity and specificity of MRI for complete tears of the LHB were 56.3% and 98.0%, respectively (positive predictive value =90.0%, negative predictive value =87.5%).

CONCLUSION

Standard noncontrast MRI of the shoulder is limited in detecting partial tears and complete ruptures of the intra-articular LHB tendon. Surgeons may encounter pathologic lesions of the LHB tendon during arthroscopy that are not visualized on preoperative MRI.

Predictive factors of long head of the biceps tendon disorders-the bicipital groove morphology and subscapularis tendon tear

BACKGROUND

Disorders of the long head of the biceps (LHB) tendon contribute to anterior shoulder pain. Although LHB tendon disorders are associated with rotator cuff disease, distinguishing between biceps and rotator cuff pathology is difficult. The objective was to identify the predictors of LHB tendon disorders associated with a supraspinatus tear.

METHODS

In 55 patients (average age, 65 years) undergoing arthroscopic rotator cuff repair, bicipital groove morphology were assessed using computed tomography, and subscapularis tear and bicipital groove effusion were assessed using magnetic resonance imaging, retrospectively. The LHB tendon was evaluated arthroscopically according to the Lafosse classification. Univariate and multivariate ordinal logistic regression analyses were conducted for injury grade with all covariates.

RESULTS

The arthroscopic evaluation of the LHB tendon showed that there were 23 shoulders classified as grade 0, 15 as grade 1, and 17 as grade 2. Univariate logistic regression analysis showed that the width and depth, a medial spur of the bicipital groove, and a subscapularis tear were significantly associated with LHB tendon disorders. Multivariate ordinal logistic regression analysis identified a medial spur and subscapularis tear as significant predictors of LHB tendon disorders.

CONCLUSIONS

The preoperative computed tomography and magnetic resonance images, notably the presence of a spur on the bicipital groove or a subscapularis tear, were useful for identifying LHB tendon disorders. When these are found in preoperative images, the clinician should evaluate the patient for the presence of an LHB tendon disorder as a pain generator.

Long Head of Biceps Tendon Management: a Survey of the American Shoulder and Elbow Surgeons

BACKGROUND

Management of symptomatic long head of biceps tendon (LHBT) pathology remains a source of debate.

QUESTIONS/PURPOSES

The purpose of this study was to identify consensus trends for the treatment of LHBT pathology among specialists.

METHODS

A survey was distributed to members of the American Shoulder and Elbow Society (ASES), consisting of three sections-demographics, case scenarios, and general LHBT pathology management. Cases presented common clinical scenarios, and surgeons reported their management preferences. Consensus responses were defined as > 50% of participants giving a single response.

RESULTS

One hundred and forty-two of 417 (34%) surgeons completed surveys. Forty-seven percent of questions reached a consensus answer. Biceps tenodesis was the overwhelmingly preferred technique in cases demonstrating LHBT pathology, as compared to tenotomy. No consensus, however, was reached regarding a specific surgical technique for biceps tenodesis. The two most popular techniques were arthroscopic tenodesis to bone and open subpectoral biceps tenodesis. Fellowship-trained arthroscopic surgeons and surgeons with a largely arthroscopic practice were more likely to perform tenodesis arthroscopically.

CONCLUSION

ASES members favored biceps tenodesis over tenotomy for surgical management of LHBT pathology, without consensus regarding a specific surgical technique.

Tendinopathy of the long head of the biceps tendon: histopathologic analysis of the extra-articular biceps tendon and tenosynovium

BACKGROUND

Bicipital tendinitis is a common cause of anterior shoulder pain, but there is no evidence that acute inflammation of the extra-articular long head of the biceps (LHB) tendon is the root cause of this condition. We evaluated the histologic findings of the extra-articular portion of the LHB tendon and synovial sheath in order to compare those findings to known histologic changes seen in other tendinopathies.

METHODS

Twenty-six consecutive patients (mean age 45.4±13.7 years) underwent an open subpectoral biceps tenodesis for anterior shoulder pain localized to the bicipital groove. Excised tendons were sent for histologic analysis. Specimens were graded using a semiquantitative scoring system to evaluate tenocyte morphology, the presence of ground substance, collagen bundle characteristics, and vascular changes.

RESULTS

Chronic inflammation was noted in only two of 26 specimens, and no specimen demonstrated acute inflammation. Tenocyte enlargement and proliferation, characterized by increased roundness and size of the cell and nucleus with proteoglycan matrix expansion and myxoid degenerative changes, was found in all 26 specimens. Abundant ground substance, collagen bundle changes, and increased vascularization were visualized in all samples.

CONCLUSION

Anterior shoulder pain attributed to the biceps tendon does not appear to be due to an inflammatory process in most cases. The histologic findings of the extra-articular portion of the LHB tendon and synovial sheath are similar to the pathologic findings in de Quervain tenosynovitis at the wrist, and may be due to a chronic degenerative process similar to this and other tendinopathies of the body.

Variation of tension in the long head of the biceps tendon as a function of limb position with simulated biceps contraction

Purpose:

This study was designed to quantify tensile forces within the intra-articular long head of the bicep tendon (LHBT) under conditions of passive limb positioning and physiologic load, which simulate contraction of the LHBT.

Materials and Methods:

A force probe was inserted into the intra-articular LHBT, just distal to its supra-glenoid origin, in six fresh-frozen cadaveric specimens. Initially, specimens were manually manipulated through 30 glenohumeral joint positions, combining humeral rotation and elbow/forearm position. In the second phase, a 55 N tensile load was applied through the LHBT in 18 limb positions. Intra-tendinous tension was recorded in all positions under both conditions.

Results:

External humeral rotation significantly increased tension with glenohumeral forward flexion (P<0.0001). Conversely, internal humeral rotation significantly increased tension with glenohumeral abduction and extension (P<0.0001). A position of glenohumeral extension and internal rotation, with the elbow extended and forearm pronated, produced the highest tension in the intra-articular LHBT (P<0.0001). Under applied load conditions, observed LHTB tension was not statistically different in any glenohumeral position (P=0.1468, power = 88%). The greater tuberosity was noted to impinge on the force probe in forward flexion and internal rotation in two specimens.

Conclusions:

Variable tensile forces are seen in the intra-articular LHBT as a function of both limb position and simulated biceps contraction. Our findings provide a thorough data set that may be used to help substantiate or refute current or future hypotheses regarding LHBT function, pathology, and clinical tests.

Clinical Relevance:

Identifying positions of glenohumeral motion, which affect LHBT tension will provide an anatomic basis for clinical tests proposed to be for diagnosing LHBT lesions, including superior labral anterior and posterior tears.

Effects of type II SLAP lesion repair techniques on the vascular supply of the long head of the biceps tendon: a cadaveric injection study

BACKGROUND

One option for the treatment of type 2 superior labral anterior to posterior (SLAP) lesions is arthroscopic repair. However, the fact that the vascular supply of the proximal long head of the biceps tendon (LHBT) arises from the soft tissue near the SLAP repair site must also be considered. The aims of this study were to evaluate the vascular channel of the proximal long head biceps tendon and to compare potential damage to the vascular supply with alternative SLAP techniques.

METHODS

Forty-five fresh cadaveric shoulders were divided into 3 groups: 9 shoulders each for the normal group and the created SLAP group, and 27 shoulders for the repaired SLAP group. SLAP group shoulders were repaired using one of 3 techniques: 2 anchors with simple sutures, 1 anchor with double sutures, or 1 anchor with a horizontal mattress suture. India ink was then injected into the acromial branch of the thoracoacromial artery. The proximal LHBT was resected for a histologic cross-sectional study. The intratendinous vascular distance was measured and compared among the groups.

RESULTS

The vascular supply of the proximal LHBT arises from soft tissue lying anterior and dorsal to the tendon origin. In the normal shoulders, the average intratendinous vascular distance was 16.9 ± 1.5 mm (95% confidence interval: 15.8-18.1). A comparison of nonrepaired SLAPs with each of the repair techniques found that using 2 anchors with simple sutures showed no significant difference in vascular distance (P = .716), whereas the other techniques showed a significant disruption of the blood supply. The differences in vascular distance among the 3 repair techniques were statistically significant (P = .0001).

CONCLUSIONS

The main vascular supply of the proximal LHBT comes from the anterior-dorsal direction. Some SLAP repair techniques can disrupt vascularization; however, the technique using 2 anchors with simple sutures, 1 anchor 3 mm anterior to the anterior border and 1 at the posterior border of the tendon, can preserve the vascularization of the LHBT.

Congenital absence of the long head of biceps tendon & its clinical implications: a systematic review of the literature

BACKGROUND

Multiple reports of congenitally absent long head of biceps tendon (LHBT) have been reported in the literature. However, there is no consensus on the clinical implications of this relatively rare entity.

STUDY PURPOSE

To systematically review and analyze all studies which have reported absence of LHBT.

METHODS

PubMed and EMBASE databases were searched. Also, a secondary search was performed by pearling the bibliography of all the full-text articles obtained. Pre defined inclusion criteria was used for abstract screening by two independent observers. Twenty three studies met our inclusion criteria, were included for the final analysis and the data was pooled. The cases were further sub-grouped according to the classification of Dierickx et al.

RESULTS

Till date, 35 cases of absent LHBT have been reported. Males and females were equally affected. Eight of these were bilateral and only four cases had other associated congenital anomalies. Majority of the patients presented with shoulder pain (85.7%) while 37.1% had shoulder instability (mainly anterior instability). The ABS type was the most common variant reported. The finding was missed in 60% of the cases on the initial MRI only to be detected later on shoulder arthroscopy.

CONCLUSIONS

Congenitally absent LHBT may not be as rare as was previously thought to be. Due to the heterogeneity and the low level of evidence of the data available, it is hard to conclude if a congenitally absent LHBT is a cause of shoulder pain/impingement or instability on its own.

LEVEL OF EVIDENCE

IV.

Translation and Cultural Adaptation to Portuguese of the Long Head of Biceps Tendon Score

Objective  To translate and culturally adapt the Long Head of Biceps Tendon (LHB) score into Brazilian Portuguese. Methods  The process involved translations by professionals fluent in the target language, followed by independent back translations. Next, a committee compared the original and translated versions, pretested the final version, and concluded it. Results  We translated and adapted the questionnaire according to the proposed methodology. In the first version in Portuguese (VP1) there was divergence regarding the translation of twelve terms. Compared to the original version, the back translation of VP1 presented eight diverging terms. A committee prepared a second version in Portuguese (VP2) and applied it to a pretest group consisting of 30 participants. Finally, we conceived the third version in Portuguese, called LHB-pt. Conclusion  The translation and cultural adaptation into Brazilian Portuguese of the LBH score was successfully accomplished.

The use of long head biceps tendon autograft for massive rotator cuff tears: a PRISMA compliant systematic review

INTRODUCTION

Rotator cuff tears (RCT) are a common cause of shoulder pain and disability, with massive RCT accounting for 10-40% of all rotator cuff tears.

SOURCES OF DATA

A systematic search of PubMed and Scopus electronic databases was performed up to August 2022, and a total of 17 scientific articles were included in the present PRISMA compliant systematic review.

AREAS OF AGREEMENT

Understanding the geometric patterns in RCT is essential to achieve appropriate repositioning of the injured tendons in their anatomic location. The long head of the biceps tendon (LHBT) is usually exposed when defects of the anterolateral corner are present and can be easily used to augment rotator cuff repairs.

AREAS OF CONTROVERSY

There are no definite guideline regarding the management of massive rotator cuff tears.

GROWING POINTS

The use of LHBT graft is safe and effective, but technically demanding. All studies were level IV articles of medium to high quality.

AREAS TIMELY FOR DEVELOPING RESEARCH

Prospective long term follow-up studies and randomized controlled trials are needed, adding imaging evaluation and appropriate clinical outcome measures at follow-up.

Long head of biceps tendon augmentation for massive rotator cuff tears improves clinical results regardless of the number of tendons involved

PURPOSE

Management of massive rotator cuff tears (MRCTs) remains debated, and various arthroscopic and open techniques have been described for their management. Nevertheless, the optimal strategy remains unclear. The present study evaluated the clinical results in patients managed arthroscopically for MRCTs augmented with the long head biceps tendon (LHBT) at a minimum 1-year follow-up, considering different type of tears, demographic data and number of torn tendons.

METHODS

Patients treated in a secondary referral centre from January 2021 to April 2022 were enroled prospectively. Inclusion criteria were pain, inability to fully elevate the affected shoulder, irreparable tears and active and motivated patients. All patients were managed within 2 months from diagnosis in a single centre by the same surgeons. Preoperative shoulder radiographs and magnetic resonance imaging (MRI) were collected, and clinical assessment was also performed using the Numerical analogue scale (NAS), Constant score (CS) American Shoulder and Elbow Surgeons Shoulder Score (ASES). Tissue retraction and tendon fatty infiltration were evaluated using Patte and Fuchs scale, respectively. Clinical assessment was performed using the same scales at 3-6 months and 1-year follow-up.

RESULTS

A total of 55 patients (31 female and 24 male) with a mean age of 60 ± 7.1 years were enroled for a mean follow-up of 18.2 ± 4.3 months. The mean preoperative NAS was 7.8 ± 0.6, CS was 20.5 ± 7.6 and ASES was 22.6 ± 9.2, increasing, respectively, to 0.3 ± 0.6, 91.5 ± 6.9 and 94.2 ± 6.7. No adverse side effects (infection, rejection, allergy) were reported during the study period. All patients were evaluated after surgery at 3 and 6 months and 1 year with statistically significant improvement for each score at the first and last follow-up (p < 0.05).

CONCLUSIONS

The use of LHBT augmentation in patients with MRCTs in appropriately selected patients is safe and effective and can lead to pain relief and acceptable clinical outcomes. Furthermore, its use carries low donor site morbidity and is cost effective. Comparative studies, including randomised controlled trials, with other proposed techniques are needed to confirm these findings.

LEVEL OF EVIDENCE

Level IV.

Impact of shoulder, elbow and forearm position on biceps tendon excursion: A cadaveric study

PURPOSE

This experimental study investigated the long head biceps tendon (LHBT) excursion that occurs at various positions of the upper limb during tendon stabilizing procedures. We hypothesized that shoulder abduction, elbow extension and forearm pronation would maximize the excursion of the LHBT and potential impacts on tendon stabilization.

MATERIALS & METHODS

Forequarter specimens from 12 fresh frozen cadavers were used in this study. The study was performed at 0° and 30° of shoulder abduction. Elbow position was either 90° of flexion or full extension with the forearm either in full pronation or supination. A total of 14 combinations of positions were studied. A load of 55 N was applied to the distal biceps. The excursion of the proximal part of LHBT was measured for each of the different positions.

RESULTS

At a shoulder position of 30° of flexion, shoulder abduction of 30° created significantly greater excursion than 0° of shoulder abduction (p < 0.001). Both full extension of the elbow and full pronation of the forearm also showed significant excursion of the tendon when compared to supination (p < 0.001).

CONCLUSIONS

The position of the shoulder, elbow and forearm has a significant effect on biceps excursion. Thirty degrees of shoulder abduction and 30° of forward flexion with the elbow in full extension and the forearm in full pronation maximizes excursion.

CLINICAL RELEVANCE

Information about the excursion of the LHBT affected by the position of the upper limb is useful for any biceps tendon stabilizing procedure. During an operation, the position of the upper limb should be monitored in order to maintain a proper anatomic length-tension relationship.

The role of elbow positioning on arthroscopic assessment of the long head of biceps tendon in the beach chair position

Background

Tendinopathy of the long head of biceps (LHB) tendon is a common cause of anterior shoulder pain and dysfunction. The extra‐articular portion within the bicipital groove undergoes frequent load and friction during shoulder movements and pathology within this area is frequently missed during arthroscopic assessment.

Methods

We quantified the arthroscopically assessable length of tendon within the shoulder in 14 consecutive patients undergoing subpectoral biceps tenodesis. After biceps tenotomy at the superior labrum, the tagged tendon was maximally tensioned and marked at the biceps outlet with the elbow in extension and flexion. The distance in distance between the two were measured.

Results

Mean distance from the superior labral insertion of the biceps to the outlet was 16.4 ± 4.1 mm (range, 11–25). With tension on the biceps with elbow extension, the mean measurable distance was 31.3 ± 6.7 mm (range, 19–45). With elbow flexion, this increased to 39.5 ± 5.9 mm (range, 25–52). Mean increase in visible tendon length was 8.2 ± 4.3 mm (range, 5–21) (p = 0.002).

Conclusion

Elbow flexion results in an average increase of 26.2% more extra‐articular tendon visualized at arthroscopy. Therefore, we believe that elbow flexion is a useful adjunct, especially when performed in conjunction with techniques that pull the tendon into the joint, thus allowing for more complete arthroscopic assessment of the LHB, increasing detection of symptomatic biceps tendonitis.

Level of evidence: Level IV.