Biceps Pathology Research Articles

Biceps Transfer Using Subdeltoid Arthroscopy

| ABSTRACT The diagnosis and treatment of biceps tendon pathology remain controversial. These patients may be more resistant to conservative treatment than those patients with standard subacromial impingement. When conser- vative treatment fails, surgical options should be explored. Tenotomy and tenodesis of the biceps tendon have been described, although persistent pain, deform- ity, and muscle cramping have been frequently reported. We describe a novel technique of biceps tenodesis by arthroscopic transfer of the long head of the biceps tendon to the anterior aspect of the lateral conjoint tendon using the subdeltoid space. The soft tissue transfer closely reproduces the native axis of pull of the biceps. It also allows soft tissue healing, which creates the normal ''bungee^ effect of the superior labrum/biceps anchor complex. This technique also allows the surgeon direct visualization during tenodesis to help prevent overtensioning of the tendon. Because of the early success of the procedure, we continue to use this technique with increasing frequency in appropriately indicated patients to access the anterior aspect of the shoulder extraarticularly.

Arthroscopic Subdeltoid Approach to the Biceps Transfer

Arthroscopy is an accepted tool in the treatment of many types of shoulder pathology. The arthroscopic subdeltoid approach consists of the posterior–portal-based arthroscope being advanced into the subdeltoid space via the subacromial space, then exposure of the space with shaving or radiofrequency ablation. The other portals are then made with a spinal needle localization piercing the anterior deltoid. This subdeltoid approach is well-suited to problems such as pectoralis major and subscapularis muscle tear, as well as massive rotator cuff tear repairs, problems that were previously difficult to address from the standard arthroscopic portals. This approach also allows transfer of the biceps tendon to the conjoint tendon. When patients continue to be symptomatic despite conservative interventions, surgical options need to be explored. Currently, there is no gold standard for the surgical treatment of biceps tendon pathology. Some authors favor tenodesis whereas others advocate tenotomy or transfer. Many of the treatments, including tenodesis and tenotomy, have had excellent rates of success, but complications, such as deformity, persist. We describe a new arthroscopic technique for biceps tenodesis via transfer of the long head of the biceps tendon to the conjoint tendon using the subdeltoid space. With this technique, the tendons are under direct visualization for proper tensioning, and the transferred tendon is approximately in the same orientation as in its native location. In the appropriately indicated patient, this technique may yield relief from biceps specific symptoms.

A Novel Approach to Arthroscopic Biceps Tenodesis

This study describes a new technique of arthroscopic biceps tenodesis termed the wedge tenodesis. The short-term results of patients undergoing arthroscopic wedge tenodesis versus open keyhole tenodesis versus tenotomy are compared. We undertook a retrospective clinical study evaluating the follow-up result of patients with refractory biceps pathology. All patients who underwent a wedge or keyhole tenodesis or biceps tenotomy from January 2002 to June 2004 were identified. Follow-up examinations were performed assessing strength, cosmetic deformity, and tenderness. The sample population included 22 wedge tenodesis, 17 keyhole tenodesis, and 10 tenotomies. This represented a 93% retrieval rate. All patients were satisfied with their respective procedures. A total of 15 of 22 wedge tenodesis, 10 of 17 keyhole tenodesis, and 2 of 10 tenotomy patients had near-normal strength in supination and flexion. Five of 22 wedge tenodesis, 1 of 17 keyhole tenodesis, and 2 of 10 tenotomy patients had tenderness to palpation in the proximal biceps groove. One wedge tenodesis, 1 keyhole tenodesis, and 8 tenotomy patients were found to have a cosmetic deformity at the proximal biceps. The arthroscopic biceps wedge tenodesis can be performed safely and effectively with respect to pain relief and maintenance of strength. Additionally, there is minimal cosmetic deformity. Early functional results are similar to the open tenodesis technique, and pain reduction is similar to the tenotomy technique.

Computed tomography analysis of the coracoid process and anatomic structures of the shoulder after arthroscopic coracoid decompression: A cadaveric study

The purpose of this anatomic study is to define the morphologic changes of the coracoid and surrounding soft tissue after arthroscopic coracoid decompression. We obtained 5 fresh-frozen forequarter cadaveric specimens, 3 female and 2 male, with a mean age of 86.2 years. Arthroscopic coracoid decompression was performed, and intraarticular pathology was documented. Preoperative and postoperative measures of coracoid overlap, coracoid index, and coracohumeral distance were made on limited-cut axial computed tomography scans. Dissection was performed to assess anatomic relationships after coracoid decompression. Arthroscopic findings revealed subscapularis pathology and glenohumeral arthritis in all specimens, long head of biceps pathology in 3, and supraspinatus pathology in 2. Gross dissection confirmed the pathologic findings. Arthroscopic coracoid decompression effectively improves coracoid overlap, coracoid index, and coracohumeral distance. The adjacent major neurovascular structures are at a safe distance from the decompression site.

Long head of the biceps pathology as a cause of anterior shoulder pain after shoulder arthroplasty

The use of shoulder arthroplasty has been increasing over the last decade, with nearly 20,000 shoulder arthroplasties being performed each year. Although many patients have excellent results, there exists a subset of patients in whom anterior catching shoulder pain develops after arthroplasty. The purpose of this study was to examine this group of patients and explore treatment options and outcomes for this condition. We undertook a review of 8 shoulders in 7 patients who were treated for anterior shoulder pain radiating into the biceps muscle after shoulder arthroplasty. Three patients had a hemiarthroplasty for fracture, and five had a total shoulder arthroplasty. All patients had anterior shoulder pain with physical examination findings consistent with biceps tendon pathology. Definitive diagnosis and treatment consisted of either arthroscopy, in 7 of 8 shoulders, or an open procedure, in 1 of 8 shoulders. The range of motion improved in all shoulders. The hemiarthroplasty group showed an increase in flexion of 36 degrees (range, 68 degrees -104 degrees ), external rotation of 23 degrees (range, 11 degrees -34 degrees ), and internal rotation to L4. The total shoulder group demonstrated an increase in flexion of 50 degrees (range, 66 degrees -166 degrees ), external rotation of 27 degrees (range, 22 degrees -39 degrees ), and internal rotation to L3. The Hospital for Special Surgery score improved in all shoulders, with all patients being satisfied with their final outcome. Pain scores improved from a mean of 6.9 (range, 4-9) preoperatively to 1.4 (range, 0.5-2) postoperatively on a scale of 1 to 10, with 10 indicating the most pain. The role of the biceps tendon in the pathology of anterior shoulder pain after shoulder arthroplasty appears to be consistent with fibrosis and inflammation. Initial results, achieved with arthroscopic debridement or tenodesis, were encouraging.

A Comparison of Supination and Elbow Flexion Strength in Patients with either Proximal Biceps Release or Biceps Tenodesis (SS-40)

Arthroscopic proximal biceps tenotomy and tenodesis are two techniques used to treat symptomatic patients with biceps pathology. We have found little functional difference between patients who have had biceps release versus tenodesis, and have observed that patients with biceps release recover quicker. No studies have evaluated strength in patients who have had an elective proximal biceps release. The purpose of this study was to establish normal data for flexion and supination and compare this to groups of patients who have had either a biceps tenodesis or release. Patients and control subjects volunteering for this study were between the ages of 20 and 70 and had either: 1) no previous shoulder surgery or other shoulder pathology (Control group) or 2) be fully recovered from shoulder surgery and at least 6 months post-operation from either biceps release or tenodesis. Subjects were classified into three groups, those with normal shoulders, those having proximal biceps release, and those having proximal biceps tenodesis. Supination and elbow flexion isokinetic strength was measured at 60 and 120 degrees per second with a Cybex dynamometer. The difference in torque between the dominant and non-dominant extremities in supination and pronation and elbow flexion and extension for the normal shoulders were used as a control. The difference in torque between the surgical shoulder (biceps release or biceps tenodesis) and the non-surgical shoulder, taking into account arm dominance, were calculated and used as the criterion measure. Torque differences between the three groups of patients were compared statistically using an analysis of variance. Seventeen biceps release, 20 biceps tenodesis and 30 age, gender and BMI matched controls subjects were tested for supination and elbow flexion strength of both arms. Comparison between groups utilizing an ANOVA showed no significant strength difference in either elbow flexion or forearm supination in control, release, and tenodesis groups. Results of this study suggest that both biceps tenotomy and tenodesis are useful in painful proximal biceps pathology. While there is no statistically significant difference in postoperative strength measurements, there was a trend towards weaker forearm supination strength in patients undergoing biceps tenotomy. We postulate tenodesis of the long head of the biceps tendon in the athlete or those requiring maximal forearm supination strength.

Shoulder Impingement Syndrome

Although there has been much research about imaging methods for shoulder impingement syndrome, the clinical information and upper limb level of disability have been generally ignored. The purpose of this study was to detect the relationships between clinical, functional, and radiologic variables in patients with shoulder impingement syndrome. A cross-sectional, clinical, and radiologic study was planned and 59 shoulders of 58 consecutive patients waiting for physical therapy because of a clinically suspected shoulder impingement syndrome were included into this study. Comprehensive clinical examination, radiography, shoulder ultrasonography, and magnetic resonance imaging were performed in the same month. Despite the high sensitivities of ultrasonography for diagnosing rotator cuff tears (98.1%) and biceps pathologies (100%), magnetic resonance imaging was superior to ultrasonography in many important shoulder structures such as a glenoid labral tear and subacromial bursal effusion/hypertrophy (P < 0.01). These structures were the determinants of the shoulder's disability measured by disabilities of the arm, shoulder, and hand questionnaire. Ultrasonography and magnetic resonance imaging had comparable high accuracy for identifying the biceps pathologies and rotator cuff tears. The basic clinical tests had modest accuracy in both disorders. The choice of which imaging test to perform should be based on the patient's clinical information (regarding lesion of glenoid labrum, joint capsule, muscle, and bone), cost, and imaging experience of the radiology department.

The Arthroscopic Active Compression Test

Pathology of the biceps tendon is often a factor in the pathogenesis of shoulder pain. However, diagnosis and management of such pathology remains controversial. Multiple tests have been described to identify pathology related to the biceps tendon and biceps anchor. The active compression test is one such test that has been used clinically to identify patients with superior labral/biceps anchor pathology. An arthroscopic version of this test is described to identify biceps pathology intraoperatively and to aid the surgeon in making diagnostic and treatment decisions.

Arthroscopic Biceps Tenodesis: Technique and Results in Six Dogs

Biceps tenodesis was performed using an arthroscopic-assisted technique on six dogs diagnosed with chronic bicipital tendon pathology. The technique was performed using two different fixation methods (i.e., cannulated interference screw, cannulated screw and tissue washer). All six dogs had successful outcomes in terms of return to full function at a mean follow-up time of 11.7 months after surgery. Arthroscopic biceps tenodesis is a feasible option for surgical management of biceps tendon pathology, and it may have advantages over open tenodesis and open or arthroscopic tenotomy. Further study is needed before definitive recommendations regarding indications, complications, and prognosis associated with arthroscopic biceps tenodesis can be made.

Accuracy of the Speed’s and Yergason’s tests in detecting biceps pathology and SLAP lesions: comparison with arthroscopic findings

Purpose The purpose of this study was to explore and describe reasons for variation in diagnostic accuracy of clinical tests using Yergason’s and Speed’s tests in predicting biceps tendon pathology and SLAP lesions. Shoulder arthroscopy was used as the gold standard. Type of study Prospective blinded study of consecutive patients with a wide spectrum of shoulder conditions. Methods One hundred fifty-two subjects (65 women and 87 men) with complaints of shoulder pain were examined. Fifty subjects (16 women and 34 men) ranging in age from 24 to 79 years (mean age, 50 years; SD = 14.36) met the criteria for surgery. The validity of the Yergason’s and Speed’s tests was evaluated against findings at surgery. Results The surgical findings related to biceps pathology and SLAP lesions were as follows: 2 bicipital tendonitis, both associated with significant rotator cuff pathology; 10 biceps partial tears; and 2 complete ruptures. Fifteen patients had SLAP lesion type I, 12 type II, and 1 type IV. The sensitivity, specificity, and positive and negative predictive values were 43%, 79%, 60%, and 65% for Yergason’s test and 32%, 75%, 50%, and 58% for Speed’s test, respectively. The likelihood ratios were 1.28 and 0.91 for Speed’s test and 2.05 and 0.72 for Yergason’s test. These ratios were provided to assist clinicians in calculating the probability of biceps pathology and SLAP lesions for a single patient with a different history-specific prevalence of having the pathology. Conclusions Although Speed’s and Yergason’s tests are moderately specific, they do not generate a large change in the post-test probability and are unlikely to make a significant change in the pretest diagnosis. Clinicians should understand that clinical examination tests do not perform consistently and have variable predictive values in different patient populations and settings. Level of evidence Level I diagnostic study: testing of previously developed criteria in a series of consecutive patients (using surgery as gold standard).

Arthroscopic biceps tenodesis: A new technique using bioabsorbable interference screw fixation

Purpose: To report a new technique of arthroscopic biceps tenodesis using bioabsorbable interference screw fixation and the early results. Type of Study: Prospective, nonrandomized study. Methods: Technique: The principle of arthroscopic biceps tenodesis is simple: after biceps tenotomy, the tendon is exteriorized and doubled on a suture; the biceps tendon is then pulled into a humeral socket (7 or 8 mm × 25 mm) drilled at the top of the bicipital groove, and fixed using a bioabsorbable interference screw (8 or 9 mm × 25 mm) under arthroscopic control. Patients: 43 patients treated with this technique between 1997 and 1999 were followed-up for at least 1 year. The technique was indicated in 3 clinical situations: (1) with arthroscopic cuff repair (3 cases), (2) in case of isolated pathology of the biceps tendon with an intact cuff (6 cases), and (3) as an alternative to biceps tenotomy in patients with massive, degenerative and irreparable cuff tears (34 cases). The biceps pathology was tenosynovitis (4 cases), prerupture (15 cases), subluxation (11 cases), and luxation (13 cases). Results: The absolute Constant score improved from 43 points preoperatively to 79 points at review (P < .005). There was no loss of elbow movement and biceps strength was 90% of the strength of the other side. Two patients, operated on early in the series, presented with a rupture of the tenodesis. In both cases the bicipital tendon was very friable and the diameter of the screw proved to be insufficient (7 mm). No neurologic or vascular complications occurred. Conclusions: Arthroscopic biceps tenodesis using bioabsorbable screw fixation is technically possible and gives good clinical results. This technique can be used in cases of isolated pathologic biceps tendon or a cuff tear. A very thin, fragile, almost ruptured biceps tendon is the technical limit of this arthroscopic technique.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 18, No 9 (November-December), 2002: pp 1002– 1012

Subacromial decompression. Treatment for small- and medium-sized tears of the rotator cuff.

We report the results of arthroscopic subacromial decompression and debridement of the rotator cuff for chronic small- and medium-sized tears in 114 patients (118 shoulders) between two and five years after surgery. The mean Constant score was improved to 69.8, and 88 shoulders (74.6%) had a satisfactory outcome. Of patients under the age of 60 years the outcome was satisfactory in 59.3%, and in those over 60 years, in 87.5% (p < 0.001). An unsatisfactory outcome was related to manual work (p < 0.001) and a duration of symptoms of more than 12 months (p < 0.05). The outcome was not related to the size of the tear, the muscles involved or biceps pathology. Further surgery was required in 25 patients after a mean of 13.7 months (3 to 35); ten tears had progressed in size, but none became irreparable. There was no relationship between the increase in the size of the tear and its initial size, the muscles involved or the presence of biceps pathology. No tear became smaller with time.

Subacromial decompression

We report the results of arthroscopic subacromial decompression and debridement of the rotator cuff for chronic small- and medium-sized tears in 114 patients (118 shoulders) between two and five years after surgery. The mean Constant score was improved to 69.8, and 88 shoulders (74.6%) had a satisfactory outcome. Of patients under the age of 60 years the outcome was satisfactory in 59.3%, and in those over 60 years, in 87.5% (p &lt; 0.001). An unsatisfactory outcome was related to manual work (p &lt; 0.001) and a duration of symptoms of more than 12 months (p &lt; 0.05). The outcome was not related to the size of the tear, the muscles involved or biceps pathology. Further surgery was required in 25 patients after a mean of 13.7 months (3 to 35); ten tears had progressed in size, but none became irreparable. There was no relationship between the increase in the size of the tear and its initial size, the muscles involved or the presence of biceps pathology. No tear became smaller with time.

Results of biceps tenotomy for treatment of pathology of the long head of the biceps brachii

Historically, the surgical treatment of bicipital pathology has been a variety of tenodesis techniques. The purpose of this study is to report the results of simple biceps tenotomy for the treatment of bicipital pathology. Thirty shoulders in 30 consecutive patients who had a simple arthroscopic biceps tendon release were reviewed. Data was collected according to the method of the American Shoulder and Elbow Surgeons (ASES) shoulder evaluation form. Outcome was assessed with the rating system of the ASES. The mean ASES shoulder score was 81.8. There was a significant reduction in pain and improvement in function after the procedure. The complication rate was 13.3%. Bicipital pathology is a significant cause of morbidity around the shoulder. The results of this study demonstrate that functional outcome as measured by the ASES scoring system can be very good with an arthroscopic biceps tendon release for the treatment of biceps tendon pathology. (J Shoulder Elbow Surg 2001;10:247-9.)

Clinical exam of the shoulder.

This paper outlines the important features of the clinical assessment of the shoulder in a systematic and thorough manner. We highlight the key symptoms, particularly pain and instability, and describe how they may be associated with the various different pathologies. The physical examination is detailed in order of inspection, palpation, and motion, and then considerable emphasis is given to specific shoulder tests looking for evidence of rotator cuff weakness, impingement, biceps pathology, and instability. A number of specific tests of instability are outlined including an examination technique for posterior instability that has not previously been described.

THE FUNCTION OF THE LONG HEAD OF THE BICEPS AT THE SHOULDER 267

The purpose of this study was to delmeate, through EMG analysis, the function of the long head of the biceps at the shoulder and to determine the specificity of manual muscle tests currently used to isolate biceps pathology at the shoulder. The shoulders of 10 subjects were examined dynamically with integrated EMG (IEMG). The long head of the biceps was instrumented with thin wire electrodes. The supraspinatus, infraspinatus, deltoid, brachialis and brachioradialis were similarly instrumented as controls. As the biceps functions primarily as a forearm supinator and elbow flexor, a brace was used to lock the elbow in extension with the forearm in neutral pronation/supination. Shoulder flexion, extension, internal and external rotation were tested in a full arc at fast (180°/sec) and slow(36°/sec) speeds with and without a 5 lb weight attached to the distal end of the brace. The brace was removed and manual muscle tests (Speed's, Yergason's and elbow flexion against resistance at 90° abduction), that are assumed to isolate bicipital activity at the shoulder were evaluated. The brachialis and brachioradialis confirmed the lack of active elbow flexion in the brace. We found that no IEMG activity was evident at the long head of the biceps muscle in response to any of the isolated shoulder motions. The deltoid, supraspinatus and infraspinatus were all variable active according to the specific motion. Yergason's, Speed's and elevated flexion testing produce high amplitude signal not only in the biceps leads, but across the supraspinatus, infraspinatus and deltoid muscles as well. The data demonstrates that the long head of the biceps is not active in isolated shoulder motion when the elbow and forearm are controlled. Any hypothesis on bicipital function at the shoulder must be based on either a passive role of the tendon or an active role that achieves tension in association with elbow and forearm activity. Manual muscle testing for the biceps is not specific for biceps pathology at the shoulder.

Prediction of Transient Heat Transfer in Foods Packaged in Retortable Pouches and Sterilized by Thermal Conduction

To analyze and correlate the clinical, radiographic, and surgical presentation of subscapularis (SSc) tears treated with arthroscopic repair.We retrospectively identified 455 patients who underwent rotator cuff tear repairs at our institution from 2010 to 2014. Of these patients, 139 underwent an SSc repair either in isolation or concurrently with other rotator cuff procedures. Tear size was classified arthroscopically by whether tears involved the superior one-third of the SSc tendon, superior two-thirds of the SSc tendon, or complete SSc tendon. Patient demographic characteristics, assessments of belly-press weakness and the lift-off test, magnetic resonance imaging (MRI) findings, and data on concurrent supraspinatus and biceps tendon pathology were collected and analyzed according to tear size.Our cohort had a mean age of 61.8 ± 12.5 years, with a male-female gender ratio of 1.7:1. There were 22 tears of the superior one-third of the SSc (16%), 96 tears of the superior two-thirds of the SSc (69%), and 21 complete SSc tears (15%). Overall, MRI diagnosis of SSc tears had a sensitivity of 83% and specificity of 70%. MRI sensitivity was associated with tear severity (P = .02), with complete tears having an MRI sensitivity of 100%; superior two-thirds, 82%; and superior one-third, 67%. Physical examination sensitivity for belly-press weakness and the lift-off test was 61% and 63%, respectively, and did not correspond with tear size. Increased SSc tear size corresponded with a history of trauma (P = .04) and the presence of concurrent supraspinatus tears (P = .03) and biceps pathology (P = .003).The diagnosis of SSc tears remains challenging because of the limited sensitivity of MRI and physical examination. The diagnostic sensitivity of MRI is associated with SSc tear size, whereas physical examination is independent of tear size. Additional associations identified in this study include increased SSc tear size corresponding with a history of trauma, presence of concurrent supraspinatus tears, and presence of concurrent biceps tendon pathology.Level III, retrospective comparative study.