Proximal biceps tendon: injuries and management

The long head of the biceps tendon is a known pain generator of the shoulder. There are numerous pathologic entities that may affect this tendon, including tendonitis, partial tearing, and subluxation. These conditions are often associated with rotator cuff tears, especially those involving the subscapularis. Operative interventions include tenotomy and tenodesis. Tenodesis can be preformed in a proximal or distal location. Subpectoral tenodesis may have a lower recurrence rate than proximal-based techniques.     

The proximal biceps tendon: tricks and pearls

The diagnosis and treatment of proximal biceps tendon injuries continue to be a challenge. The difficulty lies on determining if there is isolated biceps pathology versus concomitant rotator cuff tears or instability. Imaging modalities, such as magnetic resonance imaging, continue to provide us with the extra tool to help us confirm our suspicion of additional pathology. Symptomatic biceps tendon tears can undergo debridement, tenotomy, or tenodesis if nonoperative measures fail to provide relief. Reports from performing a biceps tenotomy often give similar functional outcomes compared with tenodesis. Cosmetic deformity on the lateral arm may be noted with tenodesis and initial fatigue. Tenodesis may subject the patient to a longer rehabilitation process and increased pain. The decision of which one should be performed lies between the physician and the patient's expectations.     

Arthroscopic biceps tenodesis: Indications and technique

Biceps tendon pathology commonly occurs in combination with other shoulder disorders, such as subacromial impingement and rotator cuff tears. Although the arthroscopic treatment of impingement and rotator cuff tears has previously been reported, arthroscopic biceps tenodesis has rarely been described. In this article, we present our technique of arthroscopic biceps tenodesis, which uses a uniquely designed Bio-Tenodesis screw system. This system allows intra-articular manipulation of the biceps tendon, ensures placement of the tendon into the base of the bone socket, allows insertion of the screw while maintaining the position and tension in the tendon, and ensures an adequate screw-tendon-bone interface.     

Rotator cuff tears in middle-aged tennis players: results of surgical treatment

BACKGROUND: Tennis players, like participants in other overhead sports, are vulnerable to rotator cuff tears. In players who continue to play into their middle-age years, the incidence of such injury increases. HYPOTHESIS: Surgical treatment of rotator cuff tears in middle-aged tennis players is largely successful in allowing return to tennis. STUDY DESIGN: Retrospective review. METHODS: We evaluated the results of surgical treatment of 51 middle-aged tennis players (average age, 51 years) with a rotator cuff tear in their dominant shoulder. Tennis participation among the group had averaged 3.5 hours per week for an average of 25 years. Forty-two patients underwent open repair of the tear with or without biceps tenodesis, whereas 9 patients underwent arthroscopic debridement of the tear with or without a biceps tenotomy. Patients were reviewed at an average of 57 months after surgery with an activities score, a subjective questionnaire, and a questionnaire regarding their postoperative participation in tennis. RESULTS: The activities score averaged 26.6 of 30 possible points. Forty-seven patients were satisfied with their result, and 40 patients were able to return to tennis at an average of 9.8 months after surgery. No difference was found in the ability to return to tennis between the open repair group and the arthroscopic debridement group. CONCLUSIONS: The results of this study indicate that it is possible for nearly 80% of middle-aged tennis players to return to participation after operative treatment of rotator cuff tears.     

Reparable rotator cuff tears with concomitant long-head biceps lesions: tenotomy or tenotomy/tenodesis?

Purpose

The aim of the study was to determine clinical, functional, and radiological results of two groups of patients affected by rotator cuff tear with concomitant degeneration of the long head of the biceps tendon treated with tenotomy/tenodesis or tenotomy.

Methods

Sixty-five patients were randomly assigned to group A (35 patients, tenotomy/tenodesis) and group B (30 patients, tenotomy). All patients underwent physical examination and simple shoulder test and Constant score scales. Moreover, they underwent dynamometric tests and power Doppler ultrasonography in order to evaluate the exact location of the long-head biceps and the vascularization of the repaired rotator cuff and of the long-head biceps.

Results

Physical examination and clinical evaluation scales showed satisfactory results in both groups, with no significant differences (n.s.). Popeye sign was detected in 5 patients (17%) of group B and in no one patient of group A. Ultrasound examination showed the LHB within the bicipital groove in 80% of group A and group B. Power Doppler ultrasonography showed signs of vascularization of the LHB in 20% of patients of group A and in 40% of group B and signs of vascularization of the repaired rotator cuff in 28% of group A and 40% of group B.

Conclusions

Long head of the biceps tenotomy combined with tenodesis does not provide any significant clinical or functional improvement than isolated tenotomy. However, the incidence of the Popeye sign is significantly higher, even though not associated with any functional disfunction.

Level of evidence

Therapeutic study, Level II.     

Tendinopathy of the tendon of the long head of the biceps

Pathologies of tendon of the long head of the biceps (LHB) are an important cause of shoulder pain. They include tendinopathy, rupture, superior labrum anterior and posterior lesions, pulley tears, and tendon instability. Conservative management of symptomatic LHB tendinopathy is commonly accepted as the first-line treatment. It consists of rest, nonsteroidal anti-inflammatory drugs, corticosteroid injections, and physical therapy. Biceps tenotomy and tenodesis are the most common surgical procedures to manage both isolated LHB pathology and biceps-glenoid complex tears combined with rotator cuff tears. However, controversy persists about the superiority of one of them because there is no evidence of significant differences in functional scores or patient satisfaction between the 2 techniques. This article provides an overview on biomechanical function of the LHB and current strategies for treatment of LHB disorders.     

Arthroscopic biceps tenodesis with interference screw fixation: The lateral decubitus position

The tendon of the long head of biceps brachii is an important stabilizer within the glenohumeral joint. Bicepstendon pathology commonly occurs in the presence of concomitant shoulder disorders, such as subacromial impingement, and rotator cuff tears. Biceps tenodesis is indicated in the case of a partial tear (50%), an unstable biceps tendon due to an incompetent medial sling, and in the presence of a torn subscapularis. This article will describe our technique of arthroscopic biceps tenodesis with biodegradable interference screw fixation. This technique uses a uniquely designed Bio-Tenodesis screw system (Arthrex Inc., Naples, FL) and is performed with the patient in the lateral decubitus position.     

Suture anchor and percutaneous intra-articular transtendon biceps tenodesis

Several arthroscopic biceps tenodesis techniques have been described for surgical management of tendonitis and/or partial thickness tears of the long head of the biceps brachii tendon resulting in recalcitrant anterior shoulder pain. This chapter describes an arthroscopic tenodesis using percutaneous intra-articular transtendon technique with suture anchor fixation. The percutaneous technique allows excellent access to the biceps tendon, and the addition of a suture anchor provides superior fixation to isolated soft tissue fixation.     

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.     

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.     

Arthroscopic release of the long head of the biceps tendon: functional outcome and clinical results

BACKGROUND: Treatment of chronic, refractory biceps tendinitis remains controversial. The authors sought to evaluate clinical and functional outcomes of arthroscopic release of the long head of the biceps tendon. HYPOTHESIS: In specific cases of refractory biceps tendinitis, site-specific release of the long head of the biceps tendon may yield relief of pain and symptoms. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Fifty-four patients diagnosed with biceps tendinitis underwent arthroscopic release of the long head of the biceps tendon as an isolated procedure or as part of a concomitant shoulder procedure over a 2-year period. Patients were not excluded for concomitant shoulder abnormality, including degenerative joint disease, rotator cuff tears, Bankart lesions, or instability. Nine of 40 patients had an isolated arthroscopic release of the biceps tendon. At a minimum of 2 years, the American Shoulder and Elbow Surgeons; the University of California, Los Angeles; and the L'Insalata shoulder questionnaires as well as ipsilateral and contralateral metrics were used for evaluation. RESULTS: The L'Insalata; University of California, Los Angeles; and American Shoulder and Elbow Surgeons scores were 77.6, 27.6, and 75.6, respectively. Seventy percent had a Popeye sign at rest or during active elbow flexion; 82.7% of men and 36.5% of women had a positive Popeye sign (P < .05); 68% were rated as good, very good, or excellent. No patient reported arm pain at rest distally or proximally; 38% of patients complained of fatigue discomfort (soreness) isolated to the biceps muscle after resisted elbow flexion. CONCLUSION: Arthroscopic release of the long head of the biceps tendon is an appropriate and reliable intervention for patients with chronic, refractory biceps tendinitis. Cosmetic deformity presenting as a positive Popeye sign and fatigue discomfort were the primary complaints. CLINICAL RELEVANCE: Although tenotomy is not the ideal intervention for patients of all ages with various shoulder abnormalities, data suggest that it may be an acceptable surgical intervention for a specifically selected cohort of individuals.     

Comparison of arthroscopic rotator cuff repair in healthy patients over and under 65 years of age

We compared the outcomes of arthroscopically repaired rotator cuff tears in 28 patients older than 65 years (the over 65 group: median age 70 years) with a control group of 28 patients younger than 65 years (the under 65 group: median age 57 years). The groups were similar in regard to sex distribution, surgical technique, and post-operative rehabilitation programmes, but different in age. After careful arthroscopic evaluation of the full-thickness rotator cuff tear, rotator cuff repair and biceps tenotomy were performed in all patients. Pre- and post-operatively, each patient was evaluated for range of motion, shoulder score (UCLA), and SF-36 self-administered questionnaire. Comparing pre- versus post-operative status at a minimum 24 months follow-up, forward elevation, internal and external rotation, modified UCLA rating system scores, and SF-36 scores improved significantly in both groups, with no significant difference between the groups. At the last follow-up, strength improved significantly in both groups, with non-significant intergroup difference. The Popeye sign was detected in 13/28 (46%) of the patients in the over 65 group and in 11/28 (39%) in the under 65 group (χ = 0.29) with non-significant difference between the two groups. In selected active patients older than 65, arthroscopic rotator cuff repair associated with biceps tenotomy (when necessary) can yield clinical and related quality of life outcomes similar to those of patients younger than 65 years.     

Arthroscopic shoulder decompression development and application. A five year experience

The purpose of this study was to critically evaluate the results of 80 consecutive subacromial decompressions in 76 patients with impingement syndrome and to assess the value of arthroscopy for subacromial decompression. The average followup was 32 months. The charts, radiographs, and clinical findings of all patients were reviewed. There were 57 males and 19 females, with a mean age of 41 years. Subjective, objective, and functional results were assessed. The greatest improvement was seen in the areas of pain with activity, pain at night, and use of medications. Impingement signs had decreased significantly at final followup. The procedure allowed an early return to work and competitive athletics. Repeat surgery was necessary in eight cases: three full thickness rotator cuff repairs, two stabilization procedures, two open debridements, and one biceps tenodesis and excision of the distal clavicle. An important finding was the number of unsuspected diagnoses that were made during arthroscopy. Twelve patients had significant labral tears, seven patients had complete rotator cuff tears, four patients had biceps tendon fraying, and two patients had loose bodies in the glenohumeral joint. In most of these shoulders the intraarticular lesions would not have been diagnosed by open subacromial decompression. Radiographic evaluation suggested that the "outlet view" can be helpful in determining depth of bony resection and may be a prognostic indicator. Patients who underwent simple decompression rather than bony resection tended to be younger and had less Stage III impingement changes, and they generally had a slightly better final outcome. Patients who had compensation injuries generally had a poorer outcome. In reviewing our results, it appears that arthroscopic subacromial decompression can be a successful alternative to open decompression. The key to success for closed decompression is related to 1) accurate diagnosis, 2) selective treatment, 3) adequate bone resection when required, and 4) repair of full thickness rotator cuff tears in the active patient. Postoperative rehabilitation, which includes early range of motion, is critical.     

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.     

The use of split deltoid-flap in the treatment of massive rotator cuff defects: a retrospective study of 61 patients

Massive and irreparable rotator cuff tears are a challenge for the orthopaedic surgeon. The purpose of this study was to report our experience with the treatment of massive and irreparable defects of the rotator cuff with a modified deltoid split transfer. Between 1996 and 2004, for all patients suffering from full-thickness tears of the rotator cuff (>5 cm tears in diameter, involving two or more tendons) were operated with a modified deltoid split transfer. A total of 61 patients (39 females and 22 males; age 61.9: range 49-75 years) were operated. Duration of symptoms before surgery averaged 9.6 months (range 3.5-14 months). The patients were followed for an average of 46 months (range 24-64 months). The operation included an arthroscopic evaluation, acromioplasty with resection of the lateral clavicular end, resection of the acromioclavicular joint and where necessary biceps tenodesis. The cuff defect was repaired by transfer of half thickness anterior deltoid-flap (3 cm x 5 cm) into the defect. All patients were evaluated both preoperatively and postoperatively with regard to pain, ability to perform activities of daily life, range of motion, strength and satisfaction. The patients subjectively rated their results-49 (80%) excellent or good outcome, seven moderate and five poor. Preoperatively, the Constant amounted 33.5 +/- 7.74 points. At follow-up, the score significantly increased to 77.57 +/- 19.74 points. The acromiohumeral distance increased from 5.1 +/- 1.4 mm to 9.1 +/- 1.5 mm. Pain free flexion improved from an average 90 degrees to an average 165 degrees (P < 0.01), and abduction improved from an average 110 degrees to an average 160 degrees (P < 0.01). The mean external rotation increased from 40 degrees to 65 degrees (P < 0.01), and internal rotation increased from 50 degrees to 70 degrees (P = 0.06). In the MRI and ultrasound examination, all patients had intact flap, except the three patients with flap necrosis. There were eight complications-three haematomas, two superficial wound infections which did not influence the outcome, and three fibrotic transformation after an early aseptic necrosis of the deltoid flap, which were re-operated. This technique is easy to perform, and it is possible to obtain a satisfactory outcome after repair of massive tears of the rotator cuff. A substantial decrease of pain, increased stability, an increase range of motion and strength can be achieved, with proper rehabilitation.     

Open techniques for repair of largeand massive rotator cuff tears

Rotator cuff tears can be a significant source of shoulder pain and weakness. Repair of full-thickness tears canimprove patient satisfaction and functional outcome. Several repair techniques have been described in the literature; these include arthroscopic and open approaches. Although arthroscopic repair has been popularized in the recent literature, it may not be optimal for some cases of large or massive rotator cuff tears. Open approaches allow greater access for mobilization and enable placement of bone tunnels for bone-tendon repair. The surgeon may readily release bursal and articular sided adhesions and mobilize the retracted tendon to its anatomic footprint on the greater tuberosity. This article describes 2 surgical approaches of open repair, the mini-open and formal open approach. Furthermore, useful techniques for tendon mobilization, bone-tendon repair, and postoperative rehabilitation for the management of large and massive rotator cuff tears are described.     

肩关节疼痛的MRI检查价值评估

目的评价MRI检查对肩关节疼痛疾病诊断的应用价值。方法分析34例肩关节疼痛患者的MRI表现,并与手术所见相对比,评估MRI对疾病诊断的准确性。结果34例患者肩关节磁共振成像扫描发现:肩袖完全撕裂、肩袖部分撕裂、肌腱炎、盂唇撕裂、滑膜炎、关节积液、肱二头肌长头腱鞘炎及肌腱脱位、肿瘤等。13例手术,其中1例MRI诊断为肌腱炎,手术结果为肩袖浅表部分撕裂;1例MRI表现正常,关节镜发现肱二头肌长头肌腱炎,其余11例手术所见与MRI表现基本一致,另21例经保守治疗,症状消失或好转。结论肩关节MRI能清晰显示出肩关节的复杂解剖结构,对慢性肩关节疼痛的病因诊断有较高的准确性,是一项有价值的检查方法。