Ultrasound-guided injection of the rotator interval synovial lining: A cadaveric validation.

Coracoid Impingement: A Prospective Cohort Study on the Association between Coracohumeral Interval Narrowing and Anterior Shoulder Pathologies (SS-09)

The rotator interval is important in shoulder stability and movement. The rotator interval is enclosed in the triangular area bordered by the subscapularis anteroinferiorly, supraspinatus posterosuperiorly, and the coracoid process medially. The rotator interval contains the long head of the biceps tendon, coracohumeral ligament, superior glenohumeral ligament (SGHL), and the middle glenohumeral ligament (MGHL). The rotator interval contains multiple static stabilizers of the shoulder, and its integrity is important for anterior and inferior stability of the shoulder, especially when the shoulder is adducted. Furthermore, external rotation of the shoulder is altered with rotator interval pathology. For surgical intervention to have success, an intimate understanding of the rotator interval structures is necessary. Rotator Interval Anatomy The rotator interval of the shoulder is the area defined by the subscapularis anteroinferiorly, the supraspinatus posterosuperiorly, and the coracoid process medially. The long head of the biceps tendon traversing in the bicipital groove exits the joint just lateral to the insertion of the subscapularis tendon on the lesser tuberosity (Fig. 1a). The coracohumeral ligament originates from the proximal third of the dorsolateral aspect of the base of the coracoid process and runs on the bursal side of the SGHL, inserting mostly on the greater tuberosity and to a lesser extent on the lesser tuberosity (Ferrari 1990; Burkhart et al. 1993; Jost et al. 2000; Fig. 1a). The superior glenohumeral ligament (SGHL) originates from the glenoid labrum, frequently with the long head of the biceps tendon (Jost et al. 2000; Fig. 1b). The SGHL fibers insert mainly into the lesser tuberosity and also form a band around the biceps tendon and insert into the greater tuberosity contributing to the roof of biceps sling (Ferrari 1990; Burkhart et al. 1993; Jost et al. 2000; Werner et al. 2000; Kask et al. 2010; Fig. 2). During its course, the SGHL borders the biceps anteriorly (Figs. 1b, 2, 3a–d). The MGHL commonly originates in the anterosuperior aspect of the labrum or the supraglenoid tubercle (SGT). The MGHL then inserts onto the inferior aspect of the lesser tuberosity (Ferrari 1990; Jost et al. 2000; Pouliart and Gagey 2005; Kask et al. 2010; Felli et al. 2012). As it enters the shoulder joint in the bicipital groove, the long head of the biceps tendon has a sling formed around it consisting of the supraspinatus, subscapularis, SGHL, and coracohumeral ligament (Fig. 3). The medial aspect of the sling consists of from deep to superficial the SGHL, coracohumeral ligament, and subscapularis tendon, respectively. The lateral aspect of the sling from deep to superficial consists of the SGHL, deep coracohumeral ligament, supraspinatus tendon, and superficial *Email: johnpeggers@gmail.com Sports Injuries DOI 10.1007/978-3-642-36801-1_10-1 # Springer-Verlag Berlin Heidelberg 2013

Different levels of pain, with various symptoms, are present in patients with rotator cuff tears. The purpose of this study was to evaluate the expression of factors related to pain on the long head of the biceps tendon (LHBT) and structures adjacent to the LHBT in patients with supraspinatus tears and to compare the differences in order to verify whether the structures are affected by the condition of the LHBT. Forty patients who underwent arthroscopic supraspinatus repair were enrolled. Patients with an intact LHBT were allocated to group 1 and patients with pathologic LHBTs were allocated to group 2. With the acquisition of tissues from the LHBT, anterior capsule, rotator interval, and subacromial bursa, the expressions of protein gene product 9.5 (PGP9.5), growth-associated protein 43 (GAP43), calcitonin gene-related peptide (CGRP), substance P, P75, S100, and CD34 were analyzed using real-time reverse transcription polymerase chain reaction and immunohistochemistry. The gene expression levels of PGP9.5 (p = 0.02), GAP43 (p = 0.03), CGRP (p = 0.007), and CD34 (p = 0.03) from the LHBT were significantly higher in group 2. PGP9.5 (p = 0.04 and p = 0.01), GAP43 (p = 0.02 and p = 0.004), and P75 (p = 0.02 and p = 0.02) from the anterior capsule and rotator interval were also significantly higher in group 2. Immunohistochemistry revealed increased expression of pain-related factors in the anterior capsule and rotator interval of group 2. Enhanced expression of pain-related factors in the LHBT, anterior capsule, and rotator interval of patients with pathologic LHBTs suggests that a pathologic LHBT functions as a pain generator itself and adjacent structures can be influenced by the condition of the LHBT.

This feature is a unique combination of text (voice) and video that more clearly presents and explains procedures in musculoskeletal medicine. These videos will be available on the journal’s Website. We hope that this new feature will change and enhance the learning experience. URL: http://journals.lww.com/ajpmr/Pages/videogallery.aspx?videoId=32 URL: http://journals.lww.com/ajpmr/Pages/videogallery.aspx?videoId=33 URL: http://journals.lww.com/ajpmr/Pages/videogallery.aspx?videoId=34 The long head of the biceps tendon (LHBT) originates from the superior labrum and the glenoid of the scapula. It lies between the supraspinatus and subscapularis tendons, namely, the rotator interval. Superior labrum anterior to posterior (SLAP) lesion is a tear of the superior labrum near the attachment of the LHBT.1 It is frequently encountered in overhead throwing activities when overloading of the LHBT occurs during extreme range of shoulder external rotation at late-cocking phase, or rapid deceleration of the arm at follow-through phase.2,3 The clinical diagnosis can be quite challenging because of its nonspecific symptoms and its frequent association with other shoulder pathology such as rotator cuff tears.1,4 Ultrasound (US) had not been considered feasible for evaluation of LHBT insertion at the superior labrum, partly owing to blocking of surrounding bony structures and inadequate penetration of ultrasound beam. Arthroscopy, arthrography, or magnetic resonance imaging is usually required for a definite diagnosis.2,5 We propose a novel method for dynamic evaluation of the LHBT insertion at the superior labrum. A low-frequency (5–8 MHz) curvilinear probe is required for better penetration and extended view. The patient places the ipsilateral hand on the waist, with the elbow pointing laterally. In this position, the LHBT is slightly rotated anteriorly and shifted from beneath the acromion. The probe is put in the oblique coronal plane at the window between the coracoid process and acromioclavicular joint, parallel to the orientation of the LHBT (Fig. 1A, left lower insert). The LHBT appears as a fibrillar hyperechoic band, coursing around the superior humeral head, and inserts on the triangular hyperechoic superior labrum (Fig. 1A). Note that the intra-articular portion of LHBT becomes hypoechoic owing to anisotropy, as the tendon goes deeper gradually. Video 1 demonstrates tracing of the LHBT from the bicipital groove to its proximal insertion.FIGURE 1: A, Long head of the biceps tendon (LHBT) (arrowheads) appears as a fibrillar hyperechoic band, coursing around the superior humeral head, and inserts on the triangular hyperechoic superior labrum (crosses). The intra-articular portion of LHBT is hypoechoic owing to anisotropy. B, Forearm supination causes the LHBT traction at the superior labrum, making the edge of the superior labrum much clear as well as the intra-articular portion of LHBT. The left lower inserts indicate probe positioning and patient posture.Dynamic examination is performed by supinating and pronating the forearm while keeping the upper arm fixed. The LHBT is stretched when the forearm is actively supinated, causing traction of the tendon at the superior labrum. The lateral edge of the superior labrum becomes better visualized as well as the intra-articular portion of LHBT (Fig. 1B). The integrity of the anterior superior glenohumeral joint and peritendinous fluid can be assessed in this maneuver. The dynamic imaging is also presented in the attached video (Video 2). The demonstration of labral insertion of LHBT allows for evaluation of a possible SLAP lesion. A dynamic stress test, by applying an inferior distraction force to the humerus, can also be done (Fig. 2 and Video 3). Investigation of a proximal LHBT lesion must be cautious owing to the anisotropy effect. It should be noted that part of the superior labrum, other than the insertion of LHBT, is difficult to evaluate by US, and arthrography or magnetic resonance imaging remains the diagnostic choices in case of SLAP lesion. Yet, with the advantages of excellent diagnostic power for accompanying rotator cuff lesions, noninvasiveness, accessibility, and relatively low-cost US can serve as a useful tool for screening for suspected SLAP and accompanying lesions and for follow-up of treatment.FIGURE 2: By applying an inferior distraction force (red arrow in the insert) to the humerus in a dynamic stress test, the integrity of the labral insertion (crosses) of the long head of the biceps tendon (arrowheads) can be evaluated for a possible superior labrum anterior and posterior lesion. The right lower insert indicates probe positioning and patient posture.

An Experimental Model for Training in Renal Transplantation Surgery With Human Cadavers Preserved Using W. Thiel’s Embalming Technique

The purpose of this study was to investigate the anatomy of the superior glenoid labrum focusing on the fiber arrangement of its components. Forty-nine embalmed shoulder girdles were removed and each posterior capsule was incised. After recording the macroscopic findings 12 superior-half glenoids were histologically examined. In nine serially sectioned glenoids, four were cut parallel to and five were cut vertical to the glenoid surface. The remaining three glenoids were radially sectioned at the clock position for each hour between 10:00 and 14:00. The superior labrum had a semi-circular fiber component along the outer margin of the glenoid. In addition, a so-called 'sheet-like structure' which branched off the rotator interval and contained many elastic fibers, attached to its anterosuperior portion. The fibers of the sheet-like structure mixes with fibers of the semi-circular component and ran posteriorward. The fibers of the long head of the biceps tendon extended posteriorward from its origin along the glenoid edge. These fibers communicated with other labrum fibers and became a major element of the posterior portion. The superior labrum is not homogenous. The posterior portion mainly consists of the robust fiber component of the long head of the biceps tendon. The anterosuperior portion includes fibers of the sheet-like structure which contains numerous elastic fibers. Tensile stress from the rotator interval might be conveyed to the anterosuperior labrum.

Ultrasound-guided injection of the shoulder via the rotator interval can be challenging. The procedure is used for arthrograms, hydrodilatation and intra-articular glenohumeral joint injections. The conventional approach to the rotator interval is from lateral to medial. However, the placement of the needle in the target zone i.e. between the coracohumeral ligament and the long head of the biceps, can be difficult and challenging. Inadvertent injection performed with the needle in the long head of the biceps tendon can result in a biceps tendon rupture. We describe a new method (Gaurav-Botchu technique) to access the target zone (between the coracohumeral ligament and the long head of the biceps tendon) via a medial to lateral approach, which increases the target zone.

To determine whether MRI can identify instability of the long head of the biceps tendon (LBT) in the rotator interval. A retrospective review was carried out of 19 patients, all arthroscopically examined, nine of whom had surgically confirmed instability of the LBT. A LBT perched on the lesser tuberosity correctly indicated all nine cases of instability with one false positive. In six of seven cases where the LBT was oval in shape, no instability of the biceps tendon existed, whereas LBT instability was present in eight of 12 patients with a flat long head of the biceps tendon. In seven of eight acutely angled intertubercular sulci there was no instability of the LBT while eight of 11 obtusely angled sulci were associated with LBT instability. By consensus impression, instability of the LBT could be determined with 67% sensitivity, 90% specificity, 86% positive predictive value, and 75% negative predictive value. A flat LBT perched on the lesser tuberosity with an obtusely angled intertubercular sulcus suggests the diagnosis of instability of the LBT in the correct clinical setting.

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.

Factors Affecting Dropped Biceps Deformity After Tenotomy of the Long Head of the Biceps Tendon

Thiel's embalming technique, first described by Thiel in 1992, conserves texture and colour in cadavers close to that observed in the living. It would appear that few anatomy laboratories use this method, and literature describing its use worldwide is sparse. The aim of our study was to conduct a worldwide survey on the use of this method. A questionnaire was sent out by mail to 311 anatomy laboratories or institutes across the five continents. There were six multiple choice questions to assess the level of awareness of Thiel's method, the frequency of its use among respondent institutions, the most frequently used solutions for conservation of cadavers and perceived obstacles to the use of Thiel's technique. 109/311 (35%) centres replied to the questionnaire; 56% of centres had previously heard of Thiel's technique, but only 11 centres (10% of respondents) used it regularly, and all of these were in Europe. Formalin remains the most widely used conservation solution around the world. Thiel's embalming technique is not widely known, and therefore, little used. The main obstacle to its wider use is likely the language barrier, since most of the publications describing Thiel's method are in German, which is not widely spoken outside of a few European countries.

To evaluate the feasibility of ultrasound-guided percutaneous tenotomy of the long head of the biceps tendon via a keyhole incision. 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. 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. This study shows that ultrasound-guided percutaneous tenotomy of the long head of the biceps tendon is not reliable.

An Analysis of the Rotator Interval in Patients With Anterior, Posterior, and Multidirectional Shoulder Instability

Over the past two decades, it has become accepted that the rotator interval is a distinct anatomic entity that plays an important role in affecting the proper function of the glenohumeral joint. The rotator interval is an anatomic region in the anterosuperior aspect of the glenohumeral joint that represents a complex interaction of the fibers of the coracohumeral ligament, the superior glenohumeral ligament, the glenohumeral joint capsule, and the supraspinatus and subscapularis tendons. As basic science and clinical studies continue to elucidate the precise role of the rotator interval, understanding of and therapeutic interventions for rotator interval pathology also continue to evolve. Lesions of the rotator interval may result in glenohumeral joint contractures, shoulder instability, or in lesions to the long head of the biceps tendon. Long-term clinical trials may clarify the results of current surgical interventions and further enhance understanding of the rotator interval.

One of the most complex regions of anatomy of the upper extremity is the rotator interval located in the anterior-superior aspect of the shoulder. Its functionality and integrity are critical for the stability and biomechanical leverage of the long head of the biceps tendon as it traverses this space. Furthermore, the rotator interval supports the forces promoting proper functioning of the glenohumeral joint, which accounts for the primary motion of the upper extremity. Pathology of the rotator interval can be challenging to diagnose both on imaging studies and arthroscopically because of its small structures, anatomic variants, and orientation of these various parts within a confined space. We discuss the normal and pathologic appearances of this region in conjunction with the appropriate anatomy and functionality of such as well as the latest treatment options.