Repair of chronic distal biceps tendon ruptures: Indications and use of tendon grafts

Reconstruction of chronic distal biceps tendon ruptures is complicated by the substantial retraction and poor quality of the remaining muscle and tendon tissue. Several types of tendon grafts have been described to augment the repair and restore length including both allografts and autografts. To date, we have found the Achilles tendon allografts to be perhaps the most reliable and versatile graft to reconstruct the chronic distal biceps tendon rupture and, when required, it has provided satisfactory clinical results in this difficult clinical setting.     

磁共振与超声在肱二头肌长头腱损伤的诊断价值比较

目的 探讨磁共振(MR)和超声(US)检查在肱二头肌长头腱损伤中的诊断价值.方法 收集肩关节镜检证实的肱二头肌长头腱损伤患者80例,均行MR及US检查,以肩关节镜检结果为评价标准,分别计算MR和US诊断肱二头肌长头腱损伤的准确性、敏感性、特异性,比较2种检查方法的有效性.结果 80例患者中,肩关节镜证实肱二头肌长头腱完全撕裂19例,部分撕裂45例,肌腱炎10例,脱位6例.MR与US诊断肱二头肌长头腱完全撕裂、部分撕裂、肌腱炎及脱位的准确性分别为98.7%、92.5%、97.5%、100%和96.2%、85.0%、96.3%、98.7%.MR与US诊断肱二头肌长头腱完全撕裂、肌腱炎及脱位准确性差异无统计学意义(P>0.05),但MR诊断部分撕裂的准确性高于US(P<0.05).结论 MR在判断肱二头肌长头腱部分撕裂优于US.US检查可作为常规检查方法用于排查怀疑有肱二头肌长头腱损伤的患者.     

US of the biceps tendon apparatus

High-resolution real-time sonography of the biceps tendon was performed on 80 patients referred for shoulder arthrography. The arthrograms and sonograms were compared at the levels of the biceps tendon groove and distal tendon. Sonography and arthrography were equally successful in facilitating the evaluation of the bony configuration of the biceps tendon groove, but sonography gave a superior image of the biceps tendon within the groove. In 16 patients, biceps tendon sheath effusions or swelling was detected using sonography; 15 of these patients had associated pathologic conditions elsewhere in the joint. Arthrograms did not disclose a biceps tendon or sheath abnormality in any of these patients. We conclude that sonography could be the imaging method of choice in patients with suspected biceps tendon lesions and that the presence of a biceps tendon or sheath abnormality indicates an increased likelihood of abnormalities elsewhere in the joint.     

Medial dislocation of the biceps brachii tendon: appearance at MR imaging

Abnormalities of the long tendon of the biceps brachii muscle commonly accompany other lesions about the shoulder, especially rotator cuff rupture, and are a frequent cause of a painful shoulder. The spectrum of abnormalities associated with medial displacement of the biceps tendon seen at magnetic resonance (MR) imaging was reviewed in six patients. MR imaging was performed on a 1.5-T system with use of a dedicated surface coil. The findings at MR imaging were correlated with those at surgery. Two types of medial displacement of the biceps tendon were identified. More frequently observed was a defect in the subscapularis apparatus that allowed intraarticular entrapment of the biceps tendon. Less commonly observed was incomplete dislocation, with the biceps tendon lying between a partially disrupted subscapularis tendon. MR imaging enabled accurate identification of medial dislocation of the biceps tendon and entrapment of the tendon within the glenohumeral joint. MR imaging also demonstrated the associated disruption of the subscapularis tendon that must be present to allow the biceps tendon access to the joint space.     

The stabilizing sling for the long head of the biceps tendon in the rotator cuff interval. A histoanatomic study

A histoanatomic study of the rotator cuff interval was done in 13 cadaveric specimens to investigate the relation of its ligamentous structures to the long head of the biceps tendon, with a special focus on revealing a stabilizing function. After macroscopic evaluation, the lateral half of the rotator cuff interval capsule was cut into three sections: medial, middle, and lateral. These sections were embedded in methacrylate, and then serial sections were made and stained for polarized light microscopy. The superior glenohumeral ligament was seen to form a fold having the macroscopic appearance of a U-shaped anterior suspension sling for the long head of the biceps tendon. Microscopic evaluation revealed an important role of the fasciculus obliquus in the roof of this sling. Fibers of the supraspinatus tendon join the posterosuperior part of the sling. The subscapularis tendon is not involved in this suspensory mechanism. As a result of these observations, we determined that the superior glenohumeral ligament and the fasciculus obliquus are the most important ligamentous reinforcements of a stabilizing sling for the long head of the biceps tendon in the rotator cuff interval. Their histologic appearance indicates they function to protect the long head of the biceps against anterior shearing stress. A lesion of this sling might lead to anterior instability of the biceps tendon.     

Biceps tendinitis and subluxation

Since the 17th century, the long head of the biceps tendon as a source of shoulder pain and its functional significance has been a source of debate. Although the term tendinitis is commonly used, overuse tendon injuries infrequently demonstrate inflammatory cells; instead, degenerative changes resulting from the failure of self-repair usually are found. Bicipital tendinitis or bicipital tenosynovitis is most often secondary to impingement beneath the coracoacromical arch. Primary bicipital tendinitis and tendinitis secondary to instability are possible, however. Through a careful history, physical examination, and appropriate imaging studies, the clinician can establish the diagnosis of disorders of the biceps tendon Arthroscopic evaluation greatly improves the diagnosis and treatment of biceps tendon and related shoulder pathology. Although the exact functional role of the biceps tendon remains incompletely defined, a growing body of evidence supports its role as a stabilizer of the glenohumeral joint. This stabilizing function should be incorporated into the treatment of biceps tendon disorders. Routine tenodesis has been replaced by a more individualized approach, taking into consideration physiologic age, activity level, expectations, and exact shoulder pathology present. New repair techniques are under development, and preservation of the biceps-labral complex is now preferred when possible.     

Bicipital groove dysplasia and medial dislocation of the biceps brachii tendon

The purpose of this study was to investigate the plain film finding of dysplasia of the lesser tubercle of the humerus and its relationship to medial dislocation of the tendon of the long head of the biceps brachii muscle as diagnosed by shoulder arthrography. Of 55 patients referred for arthrography of the shoulder because of undiagnosed shoulder pain, 12 demonstrated flattening of the medial wall of the bicipital tendon groove. Of these, 58% had medial dislocation of the biceps tendon, and 43% of patients with dislocation of the biceps tendon were also shown to have a tear of the rotator cuff. Since biceps tendon pathology has long been implicated in shoulder pain and weakness, assessment of the bicipital groove may provide important information in evaluating patients with potential abnormality of the biceps tendon.     

Imaging of the rotator cuff and biceps tendon

Several different imaging techniques are available for evaluating the rotator cuff and biceps tendon. The common disorders of impingement, rotator cuff tears and biceps tendonitis are discussed along with the role which the various imaging modalities can play in establishing their diagnosis. Plain radiographs can be helpful particularly with a history of trauma but give limited information on the soft tissues. Ultrasound is a useful and inexpensive means of assessing the rotator cuff and biceps tendon but has a number of limitations and varying reports on its accuracy. Computed tomography (CT) is most helpful in the evaluation of shoulder trauma but gives limited information on the soft tissues. Magnetic resonance imaging (MRI) is an accurate imaging modality for evaluating the rotator cuff and biceps tendon, allowing visualisation of the soft tissues and the adjacent bony structures.     

Physical examination for partial tears of the biceps tendon

BACKGROUND: The accuracy of the physical examination for tears of the long head of the biceps remains controversial. PURPOSE: The goals were 1) to characterize the occurrence of partial tears of the long head of the biceps tendon in a group of consecutive patients, and 2) to analyze the diagnostic value of various clinical tests for pathologic lesions of the proximal biceps tendon. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: Of 847 consecutive patients who underwent arthroscopic procedures for a variety of shoulder conditions, 40 were found at the time of arthroscopy to have partial biceps tendon tears. The average age of these 24 men and 16 women was 59 years (range, 18-83). Preoperative physical examinations had included 9 commonly used tests for shoulder examination. Statistical analysis included sensitivity, specificity, negative predictive value, positive predictive value, and likelihood ratios for these tests. RESULTS: The prevalence rate of partial tears was 5% (40/847) of all arthroscopic procedures. The most commonly associated conditions included rotator cuff tears (85% [34/40]) and anterior instability (7.5% [3/40]). Tenderness on palpation of the long head of the biceps tendon had a sensitivity of 53%, a specificity of 54%, and a likelihood ratio of 1.13. The sensitivity, specificity, positive predictive value, negative predictive value, and likelihood ratios for Speed's test were 50%, 67%, 8%, 96%, and 1.51, respectively. CONCLUSION: In patients with rotator cuff abnormality, the diagnosis of partial biceps tears cannot be made reliably with existing physical examination tests. Diagnostic arthroscopy is recommended, if clinically indicated, for potential partial tears of the long head of the biceps tendon. The treating physician should be prepared to treat unsuspected tears of the long head of the biceps tendon at the time of surgery.     

Combined Button and Screw Technique for Distal Biceps Ruptures

Distal biceps tendon ruptures occur almost exclusively in middle aged men, and with the “baby boomer” population reaching that age group, publications discussing this injury increased 130% from 1995-2010. As nonoperative treatment of distal biceps rupture leads to 40% reduction in elbow supination strength, 79% decrease in supination endurance, 30% loss in flexion strength, and 30% decrease in flexion endurance, operative repair is favored for most patients. The most popular and biomechanically sound method of fixation is a combined cortical button or tension-slide technique with tenodesis screw fixation at the native footprint on the bicipital tuberosity. Several studies show this method has a lower incidence of early failure, rerupture, and stronger biomechanical properties in cadaveric studies. The preferred surgical method is detailed with appropriate dissection, preparation of the distal biceps tendon, preparation of the bicipital tuberosity, and tendon fixation and early mobilization with postoperative rehabilitation to ensure proper healing and return to activity.     

Association of biceps tendon tears with rotator cuff abnormalities: degree of correlation with tears of the anterior and superior portions of the rotator cuff

OBJECTIVE: This study was performed to examine the relationship and association of abnormalities seen in the long head of the biceps brachii tendon to abnormal findings in the rotator cuff. MATERIALS AND METHODS: One hundred eleven patients underwent MR imaging for shoulder pain followed by arthroscopic or open shoulder surgery from January 1997 to December 2000. Patients were identified by a retrospective search, and all consecutive patients having undergone both MR imaging and surgery were included in the patient cohort. Official MR imaging interpretations were compared with operative reports, and all findings were recorded. RESULTS: Twenty-three patients were identified with partial- or full-thickness tears of the long head of the biceps tendon. The sensitivity, specificity, and accuracy of unenhanced MR imaging of the shoulder for detecting these bicipital tears were 52%, 86%, and 79%, respectively. When a tear was present in the biceps tendon, the prevalence of supraspinatous, infraspinatus, and subscapularis tendon tears was 96.2%, 34.6%, and 47.1%, respectively. Patients with biceps tendon tears were significantly more likely to also have subscapularis tendon tears (p < 0.0001) and supraspinatous tendon tears (p < 0.008) than those patients who did not have biceps tendon tears. No significant relationship was found between the presence or absence of a biceps tendon tear and the presence or absence of a infraspinatus or teres minor tendon tear (p = 0.17). CONCLUSION: Tears of the long head of the biceps tendon have a statistically significant association with tears of the anterior and superior rotator cuff and are highly correlated with tears of the supraspinatous and subscapularis tendons. When tears of these tendons are detected, specific attention directed toward the long biceps tendon is warranted to characterize the status of this structure that provides additional stability to the shoulder joint.     

Tear of the distal biceps branchii tendon: a new method of ultrasound evaluation

Tear of the distal biceps brachii tendon is an uncommon injury. Ultrasound evaluation of the distal tendon using an anterior approach is often difficult because of technical factors. We describe a new method of ultrasound evaluation of the distal biceps tendon insertion. This involves a posterior approach with the forearm pronated. With pronation of the forearm, the radial tuberosity faces posteriorly, bringing the distal biceps tendon insertion into view. A surgically proven case of distal biceps tendon tear is presented to illustrate our technique.     

Plane Talk About Shoulder Radiographs

Abstract

The biceps brachii is a unique muscle with 2 proximal tendons and a single distal tendon. Although these tendons are part of the same muscle, they have significantly different functions. It is hypothesized that the long head of the biceps acts as a pain generator in the shoulder, though the biomechanical function is still under debate. Conversely, the distal biceps tendon is the major supinator of the forearm and serves a secondary flexor. As such, injuries to these tendons must be evaluated independently. Biceps brachii ruptures most often occur in middle-aged men following a traumatic event. Injuries to the long head of the biceps are primarily treated nonoperatively with adequate results. Injuries of distal tendon occur less often, but are receiving significant attention in the literature in regard to treatment options. Surgical repair of distal biceps ruptures is indicated in patients who want to restore supination strength and endurance. It is unclear which operative technique is superior, although the most recent data suggest increased strength of the cortical button repair. This article provides a comprehensive review of both proximal and distal biceps brachii ruptures in addition to our treatment algorithm.     

Snapping of bilateral biceps femoris tendons: A case report and brief review

Snapping of the biceps femoris tendon is a rare cause of lateral knee pain often due to multiple factors including fibular head deformity and thickening of the anterior band of the biceps femoris tendon inserting on the tibia. Understanding the complex and poorly understood anatomy of the biceps femoris tendon is crucial and essential for proper diagnosis of its snapping. In this report, we describe the rare entity of bilateral biceps femoris tendon snapping in a young man using a multimodality diagnostic approach.     

Ultrasound-guided percutaneous tenotomy of the long head of the biceps tendon: a non-reliable technique

Purpose

To evaluate the feasibility of ultrasound-guided percutaneous tenotomy of the long head of the biceps tendon via a keyhole incision.

Methods

This was an anatomical study performed on twelve embalmed cadaveric shoulder joints. The rotator cuff and the position of the long head of the biceps tendon were explored by ultrasound prior to beginning the procedure. The biceps tenotomy was performed under ultrasound guidance by a highly experienced sonographer who was trained in shoulder tendon exploration. Arthroscopic exploration of the shoulder was performed immediately after the percutaneous biceps tenotomy to assess the quality and the location of the biceps tenotomy.

Results

Three out of twelve tendons (25%) were completely sectioned at the level of the glenoid insertion. More seriously, iatrogenic lesions of the cartilage of the humeral head, the supraspinatus tendon and the subscapularis tendon were observed.

Conclusion

This study shows that ultrasound-guided percutaneous tenotomy of the long head of the biceps tendon is not reliable.     

Arthrography of the biceps tendon

The purpose of this study was to analyse the factors having an influence on the arthrographic imaging of the biceps tendon. The study comprised 174 patients suffering from chronic shoulder pain. They underwent conventional shoulder arthrography with sodium meglumine metrizoate or metrizamide as a contrast medium. In the patients with a full-thickness tear of the rotator cuff, the biceps tendon sheath failed to fill with contrast medium more often than in those with an intact tendinous cuff. Metrizamide filled the biceps tendon sheath more readily than sodium meglumine metrizoate in patients with a full-thickness tear of the rotator cuff. The volume of the contrast medium injected had no influence on the imaging of the biceps tendon.     

Ultrasound assessment in distal biceps tendon injuries: Techniques,pearls and pitfalls

Ultrasound assessment of the distal biceps tendon is challenging. The tendon has two components which are continuations of the long and short heads of the muscle, and these undergo 90° of rotation along their course. The tendon has a deep insertion to the radial tuberosity. Therefore, a combination of approaches and examination techniques are utilized to ensure complete evaluation. The various ultrasound approaches used to assess the distal biceps tendon, with their advantages and limitations, will be described. Selected examples of distal biceps tendon injuries, with magnetic resonance imaging (MRI) correlation in challenging cases, will be demonstrated.     

Operative treatment of chronic distal biceps tendon ruptures

Chronic biceps tendon ruptures typically involve tendon retraction, scarring, and even compromised tissue. Indirect repair, such as tenodesis to the brachialis, does not provide optimal functional recovery. Chronic biceps tendon ruptures can be reconstructed with autogenous grafts (semitendinosis, tensor fascia lata) or allografts (typically Achilles tendon). The complications associated with these grafts include harvest site morbidity and graft incorporation. Using a vascularized local soft tissue source could minimize complications of graft reconstructions. The authors provide a novel reconstructive technique, reconstruction using the lacertus fibrosis, as a local graft source for chronic distal biceps tendon ruptures.     

Subpectoral biceps tenodesis

The long head of the biceps brachii (LHB) tendon has long been recognized as a source of shoulder pain. Surgeons have debated the merits of tenotomy versus tenodesis, open versus arthroscopic approaches, and various fixation methods. This article reviews the clinical findings associated with LHB pathology, describes the operative technique of subpectoral biceps tenodesis, and reviews the current literature related to treatment of the symptomatic LHB tendon. The miniopen subpectoral approach is technically less demanding than purely arthroscopic techniques, and offers the potential for improved pain relief without cosmetic deformity by removing most of the LHB and its associated tenosynovium. As the literature on the topic continues to grow, subpectoral biceps tenodesis has emerged as an effective treatment for pathology of the LHB.     

Magnetic resonance imaging of the long head of the biceps tendon: benefit of coplanar image

PURPOSE: To evaluate coplanar imaging of the long head of the biceps tendon. METHODS: We retrospectively compared coronal oblique magnetic resonance images aligned with the principal supraspinatus tendon and with the intra-articular biceps tendon in 21 patients. Magnetic resonance images were analyzed for lesions depicted, including superior labral anteroposterior (SLAP) tears. Arthroscopic findings were reviewed. RESULTS: Coronal oblique images aligned with intra-articular biceps tendon depicted 18 (86%) of 21 coplanar intra-articular biceps tendons. Coplanar images identified 6 cases of tendinosis, 1 tear, 3 intra-articular ruptures, and 20 (95.2%) of 21 exact origins of the tendon. Arthroscopy revealed 18 SLAP tears. The detection of SLAP lesions between both coronal oblique magnetic resonance images was significantly different (P = 0.007). CONCLUSION: Advantages included imaging of the intra-articular biceps tendon with least partial-volume effects, definition of SLAP lesions and the tendinous origin at the supraglenoid tubercle, depiction of intra-articular bicipital ruptures, and increased sensitivity and specificity for intra-articular lesions.