Introduction and purpose: Our aim was to determine a morphometric relation between the long head of the brachial biceps and the bicipital groove with respect to the subscapular tendon, and its repercussion on functional imbalance of the shoulder. Materials and methods: For this analytical observational crossover study we took a sample of 30 right-handed, sedentary, duly informed male subjects. The morphometric study was carried out with ultrasonography using a cross-section of the long head of the brachial biceps. Results: In the dominant limb: 1. Bicipital groove (depth 2.6 mm, width 13.4 mm, internal angle 149.8°); 2. Long head of the brachial biceps (area 1.35 mm, internal angle 152.53°, echogenicity 97.95); 3. Subscapular thickness 4.53 mm. In the non-dominant limb: 1. Bicipital groove (depth 2.9 mm, width 12.5 mm, internal angle 145.73°); 2. Long head of the brachial biceps (area 1.07 mm, internal angle 141.32°, echogenicity 112.72); 3. Subscapular thickness 4.12 mm. Conclusions: The greater the thickness of the subscapular tendon: 1. Bicipital groove (greater width and internal angle, less echogenicity and depth); 2. Long head of the brachial biceps (greater area and internal angle, less echogenicity). Therefore, there is a greater risk of dislocation of the long head of the brachial biceps and functional instability of the shoulder

Aims

This study aims to describe a new method that may be used as a supplement to evaluate humeral rotational alignment during intramedullary nail (IMN) insertion using the profile of the perpendicular peak of the greater tuberosity and its relation to the transepicondylar axis. We called this angle the greater tuberosity version angle (GTVA).

Background. Humeral retroversion is variable among individuals, and there are several measurement methods. This study was conducted to compare the concordance and reliability between the standard method and 5 other measurement methods on Twodimensional (2D) computed tomography (CT) scans. Methods. CT scans from 21 patients who underwent shoulder arthroplasty (19 women and 2 men; mean age, 70.1 years [range, 42 to 81 years]) were analyzed. The elbow transepicondylar axis was used as a distal reference. Proximal reference points included the central humeral head axis (standard method), the axis of the humeral center to 9 mm posterior to the posterior margin of the bicipital groove (method 1), the central axis of the bicipital groove –30° (method 2), the base axis of the triangular shaped metaphysis +2.5° (method 3), the distal humeral head central axis +2.4° (method 4), and contralateral humeral head retroversion (method 5). Measurements were conducted independently by two orthopedic surgeons. Results. The mean humeral retroversion was 31.42° ± 12.10° using the standard method, and 29.70° ± 11.66° (method 1), 30.64°± 11.24° (method 2), 30.41° ± 11.17° (method 3), 32.14° ± 11.70° (method 4), and 34.15° ± 11.47° (method 5) for the other methods. Interobserver reliability and intraobserver reliability exceeded 0.75 for all methods. On the test to evaluate the equality of the standard method to the other methods, the intraclass correlation coefficients (ICCs) of method 2 and method 4 were different from the ICC of the standard method in surgeon A (p < 0.05), and the ICCs of method 2 and method 3 were different form the ICC of the standard method in surgeon B (p < 0.05). Conclusions. Humeral version measurement using the posterior margin of the bicipital groove (method 1) would be most concordant with the standard method even though all 5 methods showed excellent agreements

Purpose. The presence of a Hill-Sachs lesion is a major contributor to failure of surgical intervention following anterior shoulder dislocation. The relationship between lesion size, measured on pre-operative MRI, and risk of recurrent instability after surgery has not previously been defined. Hypothesis: We hypothesized that the size of Hill-Sachs lesions on pre-op MRI would be greater among patients who failed soft tissue stabilization when compared to patients who did not fail. We also hypothesized that the existence of a glenoid lesion would lead to failure with smaller Hill-Sachs lesions. Method. Nested case-control analysis of 114 patients was performed to evaluate incidence of failure after soft tissue stabilization. Successful follow-up of at least 24 months was made with 91 patients (80%). Patients with recurrent instability after surgery were compared to randomly selected age and sex matched controls in a 1:1 ratio. Pre-operative sagittal and axial MRI series were analyzed for presence of Hill-Sachs lesions, and maximum edge-to-edge length and depth as well as location of the lesion related to the bicipital groove (axial) and humeral shaft (sagittal) were measured. Results. Of 91 patients included in analysis, 77 (84.6%) had identifiable Hill-Sachs lesions. 32 patients (35.2%) suffered from failure of soft tissue stabilization (redislocation 22.0%; subjective instability 13.2%). Ten of these patients (11.0%) underwent further surgery. When comparing the age and sex matched failure and control groups, statistically significant differences in unadjusted data were found for axial edge-to-edge length (p = 0.01), axial depth (p = 0.01), and sagittal edge-to-edge length (p = 0.04), with larger sized lesions found in the failure group (Figure 1). Differences trended towards significant for sagittal depth and angle from the bicipital groove. Conclusion. In this retrospective case-control study, humeral head defect size was positively correlated with recurrent instability after soft-tissue stabilization. Larger Hill-Sachs lesions, as measured on pre-op MRI, were found in patients who failure surgical intervention when compared to patients who did not fail. These data and future studies may help determine pre-operative clinical guidelines for the treatment of anterior shoulder dislocation

Introduction: We have devised a new technique of lesser tuberosity osteotomy with double row fixation of the subscapularis using suture anchors. Aim: To evaluate the biomechanical properties of this novel technique against two established methods of subscapularis repair including tendon to tendon and transosseous repairs. Method: Matched pairs of human cadaveric shoulders were allocated into 3 groups. Group 1 consisted of the double row technique with incision of the subscapularis along the bicipital groove with a lesser tuberosity osteotomy. A double loaded suture anchor was placed along the medial border of the osteotomy site and sutures were passed through subscapularis medial to the bone island in a horizontal mattress manner. A second anchor was inserted along the lateral border of the osteotomy site and the two sutures were tied onto the subscapularis holding sutures. In group 2, the subscapularis was divided 1cm medial to the bicipital groove and repaired with tendon to tendon suturing. In group 3, the subscapularis was repaired to the cut humeral neck through transosseous tunnels. The cyclic elongation, load to failure, displacement and mode of failure were analysed. Results: All specimens in Group 1 and 40% of Group 2 and 3 passed the cyclic loading test. The ultimate tensile strength in Group 1 was found to be 2.8 times that of Group 2 and 2.4 times that of Group 3 (p< 0.05). Simple suturing failed by suture cutting out of soft tissue and tranosseous repair failed by a combination of the suture cutting out through bone and soft tissue. Conclusion: This novel technique is simple to perform and biomechanically stronger than established methods of repair. A stronger fixation may allow early mobilization without the risk of tendon rupture and is much less likely to loosen with gap formation and subsequent fibrous tissue interposition. Additional advantages include bone to bone healing without violation of the subscapularis tendon

Purpose: We report a new pathological entity involving the long head of the biceps tendon (LHBT). In this entity, the hypertrophic LHBT becomes incarcerated in the joint during limb elevation, leading to shoulder pain and blockage. Material and methods: Twenty-one patients were identified. These patients presented hypertrophy of the intra-articular portion of the LHBT with tendon incarceration at limb elevation. The diagnosis was confirmed during open surgery (n=14) or arthroscopy (n=7). All cases were diagnosed in patients with an associated cuff tear. Treatment consisted in resection of the intra-articular portion of the LHBT and appropriate treatment of the cuff. Results: All patients had anterior shoulder pain and deficient anterior flexion because of the incarcerated tendon. An intra-operative dynamic test consisted in raising the arm with the elbow extended, providing objective proof of the tendon trapped in the articulation in all cases. The positive “hour glass” test produce a fold then incarceration of the tendon between the humeral head and the glenoid cavity. Tendon resection after tenodesis (n=19) or biopolar tenotomy (n=2) yielded immediate recovery of passive complete anterior flexion. The Constant score improved from 38 points preoperatively to 76 points at last follow-up. Discussion: The “hour glass” long biceps tendon is caused by hypertrophy of the intra-articular portion of the tendon which becomes unable to glide in the bicipital groove during anterior arm flexion. 10°–20° defective motion, pain at the level of the bicipital groove, and images of a hypertrophic tendon are good diagnostic signs. The “hour glass” LGBT must not be confused with retractile capsulitis. The definitive diagnosis is obtained at surgery with the “hour glass” test which shows a fold and incarceration of the tendon during anterior flexion with an extended elbow. Simple tenotomy is insufficient to resolve the blockage. The intra-articular portion of the tendon must be resected after bipolar tenotomy or tenodesis. Conclusion: Systematic search for “hour glass” LHBT should be undertaken in patients with persistent anterior shoulder pain of unexplained origin associated with deficient anterior arm flexion

Introduction: A secure repair of the subscapularis represents an integral part of any surgery involving the anterior approach to the shoulder. Dysfunction of the subscapularis leads not only to poor functional results but also to anterior joint instability which is potentially untreatable. We have devised a new technique of double row fixation of the subscapularis using two suture anchors. Aim: To evaluate the biomechanical strength of this double row technique against the established methods of simple suturing and transosseous repair techniques. Method: Twenty matched pairs of human cadaveric shoulders were allocated into 3 groups. Group 1 consisted of 10 shoulders repaired with the double row technique. This involved incising the subscapularis along the bicipital groove and a lesser tuberosity osteotomy carried out leaving the subscapularis attached to a thin island of bone. A suture anchor (Twinfix) was then inserted just medial to the osteotomy site and the tendon repaired to bone using two horizontal mattress sutures. A second anchor was inserted laterally to supplement the repair with two simple suture knots. The remaining 10 contralateral shoulders were allocated equally between groups 2 and 3. In group 2, the subscapularis was divided longitudinally 1cm medial to the bicipital groove and repaired with simple interrupted suture knots. In group 3, the subscapularis was incised at its insertion to lesser tuberosity and the tendon repaired to the osteotomy site by multiple transosseous sutures through drill holes in the anterior humeral cortex. The suture material used in all three groups was identical and consisted of an ultra high molecular weight poly-ethylene suture (Ultrabraid). To simulate the direction of pull of the subscapularis, the testing block was tilted 45 degrees while a vertically applied distraction force was applied. A custom made jig was used to measure the amount of displacement in response to a gradually applied load. All specimens were tested to failure. The mode of failure of each fixational construct was recorded. Results: The load to failure was found to be significantly higher in the double row repair technique compared to simple suturing and transosseous methods. Simple suturing failed by suture cutting out of soft tissue and tranosseous repair failed by a combination of the suture cutting out through bone and soft tissue. Conclusion: This new double row technique is simple to perform and preliminary biomechanical testing has shown this to be superior in terms of fixational strength compared to established methods. Additional advantages of this technique which have not been taken into account in this in vitro study include non violation of the subscapularis tendon with bone to bone healing

Periprosthetic fractures occur in approximately 1–3% of case series. Periprosthetic fractures are associated with revision surgery with difficult exposure, osteoporosis, large canal filling non-cemented stem design, overreaming of the medullary canal, and excessive external rotation with inadequate exposure. Periprosthetic fractures can be intentional when removing a well-fixed humeral stem. In this circumstance a longitudinal unicortical osteotomy along the anterior length of the stem will allow for stem and cement removal without fragmentation of the humeral bone. Periprosthetic fractures are classified as occurring intraoperative versus postoperative as well as the location of the fracture in relation to the stem. Most intraoperative humeral fractures and all diaphyseal fractures should be x-rayed at the time of their occurrence to determine the fracture configuration, the best exposure for repair, and the length of the stem required to internally fix the fracture. Under ideal circumstances the stem should be of sufficient length to extend two cortical widths past the distal most extent of the fracture site. For fractures limited to one or both of the tuberosities, the surgical neck, or metaphyseal-diaphyseal junction, a standard length prosthetic is sufficient. For diaphyseal fractures a long stem prosthetic is necessary. In the vast majority of fractures in which the fracture fragment is displaced, open reduction and cerclage fixation with heavy suture or wire is needed. For fractures in which the proximal bone is intact and of good quality thereby providing good prosthetic fixation and rotational stability, the diaphyseal fracture can be anatomically reduced and secured with two or three cerclage wires (Dall Meyers cables or the equivalent). In this case a non-cemented long stem prosthetic is preferred. When a cemented stem is used, it is necessary to insure that cement is not extruded from the fracture site. This is accomplished by having adequate surgical exposure of the fracture, an anatomic reduction, and secure fixation before you place the cement and stem. Extruded cement may result in nerve injury or nonunion. Intentional longitudinal fractures require direct exposure of the length of the osteotomy to control its length and displacement. It is advised to pass the cerclage wires prior to making the osteotomy. In the humerus, the osteotomy is best made just lateral to the biceps groove with an osteotome. The osteotome is placed to the depth of the stem and through the cement mantle when this is present. When the osteotomy is nearly to the length of the stem the osteotome is placed at the proximal extent of the osteotomy at approximately the mid-level of the biceps groove to a depth of the stem and then turned. This will crack the cement mantle of the opposite side of the medullary canal and open the anterior cortex. It results in a stable fracture of the humeral shaft but allows easy removal of the stem and facilitates removal of the stem from both the proximal aspect of the medullary canal and from the osteotomy site. After completion of the stem and cement removal the cerclage wires are tightened and the new stem is inserted. When secure fixation is achieved with a periprosthetic fracture, regardless of the type of fracture, the postoperative rehabilitation is the same as a routine arthroplasty and the results and time for recovery is unchanged. Nonoperative treatment of periprosthetic fractures are reserved for the postoperative fracture occurring below the stem in a patient with a well-fixed and a functioning prosthetic, or in patients that have medical contraindication to revision surgery. A functional hinged brace can be used to help in reduction of these fractures and immobilisation of the fracture site. The braces are difficult to use and are less effective in patients with a large soft tissue envelope. Skin problems and nonunions or malunions can occur. In most cases when there is an inadequate reduction, difficult immobilisation, or stem involvement, it is best to operate soon after the fracture as late revisions in the setting of a nonunion or malunion are difficult surgical challenges

Revision of the humeral component in shoulder arthroplasty is frequently necessary during revision surgery. Newer devices have been developed that allow for easy extraction or conversion at the time of revision preserving bone stock and simplifying the procedure. However, early generation anatomic and reverse humeral stems were frequently cemented into place. Monoblock or fixed collar stems make accessing the canal from above challenging. The cortex of the Humerus is far thinner than the femur and stress shielding has commonly led to osteopenia. Many stem designs have fins that project into the tuberosities putting them at risk for fracture on extraction. Extraction starts with an extended deltopectoral incision from the clavicle to the deltoid insertion. The proximal humerus needs to be freed from adhesions of the deltoid and conjoined tendon. The deltopectoral interval is fully developed. Complete subscapularis and anterior capsular release to the level of the latissimus tendon permits full exposure of the humeral head. After head removal the stem can be assessed for loosening and signs of periprosthetic joint infection. The proximal bone around the fin of the implant should be removed from the canal. If possible, the manufacturer's extractor should be utilised. If not, then a blunt impactor can be placed from below against the collar of the stem to assist in extraction. With luck the stem can be extracted from the cement mantle. If there is no concern for infection, the cement-in-cement technique can be used for revision. Otherwise, attempts should be made to extract all the cement and cement restrictor, if present. The small cement removal tools from the hip set can be used and specialised shoulder tools are available. An ultrasound cement removal device can be very helpful. The surgeon must be particularly careful to avoid perforation of the humeral cortex. This is especially important when near the radial nerve as injury can occur. When a well-fixed stem is encountered, an osteotomy of the proximal humerus is necessary. The surgeon can utilise a linear cut with an oscillating saw along the bicipital groove for the length of the implant. An osteotome is used to crack the cement mantle allowing stem extraction. Alternatively, a window can be created to offer additional access to the cement mantle. In the event the surgeon has required an osteotomy or window, cerclage wires, cables or suture will be needed and when the bone is potentially compromised, allograft bone graft struts (tibial shaft) are used for additional support. Care is needed when passing cerclage wires to avoid injury to the radial nerve which is adjacent to the deltoid insertion. If infection is suspected or confirmed an ALBC spacer is placed. When single stage revision is planned both cemented and uncemented stem options are available. Cement placed around the humeral stem has been suggested to decrease infection incidence. Revision of cemented humeral stems is a continued challenge in revision shoulder surgery. Newer systems and reverse total shoulder options have improved the surgeon's ability to achieve good outcomes when revising prior shoulder arthroplasty

Purpose:. The objective of this study was to determine the tensile strength of the different components of the rotator cuff tendons and their relationship to rotator cuff tears. Method:. The tests were done on a newly designed and built test-bench that performed the tests at a consistent rupture speed. The tests were done on four fresh frozen cadaver shoulders. The capsular and tendinous layers of the rotator cuff were divided leaving them only attached on the humeral side. Separate tensile tests were done on these tendons, after they were divided into 10 mm wide strips before testing. The tendon thickness was also measured. Results:. The maximum force tolerated by these tendons is comparable. The elongation however is not the same; the tendinous part of the tendon elongated more. The strength of the “rotatorhood” was then determined. This is a thin layer of tendon extending beyond the greater tuberosity, connecting the supra-spinatus to the sub-scapularis via the bicipital groove. The 10 mm of the “rotator hood” ruptured at an average force of 70 Newtons. Conclusion:. 1. The two layers of the rotator cuff contribute equally to the cuff's strength. 2. The difference in elongation of the tendinous and capsular layers makes the capsular layer more vulnerable to elongation stress. 3. The “rotatorhood” is a strong important structure with a mechanically advantageous insertion

The long head of biceps tendon has been proposed as one of the pain generators in patients with rotator cuff tears. Many surgeons routinely perform tenotomy or tenodesis of the LHB especially in cases of large or massive RC tears. Purpose of this study is to evaluate the condition and position of the tenotomised LHB at a minimum of one year postoperatively. Between 2006 and 2008 96 patients (41 men and 55 women) with RC tears were treated arthroscopically in our clinic, with an average age of 61.2 years (56–80). In 57 cases we proceeded to tenotomy of the LHB. Thirty one of them were available for ultrasound evaluation of the condition and the position of the tenotomised LHB one year post –tenotomy. Intraoperatively the lesions of the LHB varied in degrees from significant hypertrophy- Hourglass deformity (6 cases), subluxation (10 cases), tendinitis (25 cases) to fraying (10 cases). Twelve months postoperatively all the patients reported pain relief and satisfaction from the operation, even in irreparable tears. On ultrasound control the tendon was not found in the bicipital groove or was at its peripheral margin in 10 cases (31%) with only 3 patients having a positive Popeye sign. In the remaining patients the tendon was adhered on the wall of the groove (natural tenodesis). Our results suggest that simple tenotomy of LHB results in pain relief and maintenance of muscle strength. The low percentage of Popeye Sign disputes the necessity for tenodesis, even in younger patients

Purpose: The success of humeral head replacement following fracture is reliant on several factors, one of which is version. The correct humeral version (HV) is highly variable, and is patient and side dependent. In the setting of fracture, there is no intra-operative landmark to guide the surgeon as to the anatomic version. This study has examined computed tomography (CT) of the shoulder and compared the HV to the metaphyseal version (MV) to evaluate reliability in predicting the anatomic version. Method: A retrospective review of 50 shoulder CT scans was carried out. Patients were excluded if the anatomy prevented HV or MV evaluation. The HV and MV was measured by 2 independent evaluators. Inter and intra-rater reliability was performed. Results: There were 27 right and 23 left shoulder CT’s reviewed. The mean age of patients was 45.3 (range 13–85). The difference between the MV and HV was approximately 2.8 (95% CI 0.63–5.1). Inter and intra-rater reliability was 0.966 and 0.984, respectively. Conclusion: Determining the version of the humeral head in the setting of fracture is difficult and highly inaccurate. The biceps groove has been previously cited as a landmark for arthroplasty position, however, given the anatomic variability, version may be miscalculated. We have demonstrated the medial calcar of the proximal humerus is within 3 degrees of the actual humeral head version. This CT guided approach is novel, reproducible and demonstrates excellent reliability. It is both accurate and consistent and may be successfully utilized in the setting where normal anatomic landmarks are absent, such as fracture

PURPOSE. We performed an anatomical study to clarify humeral insertions of coracohumeral ligament (CHL) and superior glenohumeral ligament (SGHL) and their relationship with subscapularis tendon. The purpose of our study was to explain the « Comma Sign » observed in retracted subscapularis tears treated by arthroscopy. MATERIAL AND METHODS. 20 fresh cadaveric shoulders were dissected by wide delto-pectoral approach. After removal the deltoid and posterior rotator cuff, we removed humeral head on anatomical neck. So we obtained an articular view comparable to arthroscopical posterior portal view. We looked for a structure inserted on subscapularis tendon behind SGHL. By intra-articular view we removed SGHL and CHL from the medial edge of the bicipital groove, then subscapularis tendon from lesser tuberosity. We splitted the rotators interval above the superior edge of subscapularis tendon and observed the connections between subscapularis tendon, CHL and SGHL. RESULTS. 6 shoulders had massive cuff tears and were excluded. No ligamentous structure was visible between rotators interval and subscapularis tendon by simple intra and extra-articular examination. After removal of LGHS humeral insertion, no structure showed vertical attach on tendon yet. But after removal of subscapularis tendon from lesser tuberosity and medial traction we saw constantly a fibers bundle directly inserted onto supero-lateral edge of subscapularis tendon. DISCUSSION/CONCLUSION. Most authors agree about existence of CHL and SGHL and their bone insertions, whereas relations between themselves and subscapularis tendon aren't so well defined. We constantly found an effective link between subscapularis tendon and a fibers bundle mainly coming from LCH. It layed into supero-lateral edge of subscapularis tendon and could be seen only by medial traction of it. This ligamentous structure yields the « Comma Sign » in subscapularis tendon tears. This study confirms our clinical datas

We describe the technique of open reduction and fixation of displaced 2 and 3 part proximal humeral fracture, in which, two ‘figure of 8’ heavy braided sutures are passed through drill holes deep to the bicipital groove and passed through the fracture fragments and the cuff in a tension band fashion. A series of 12 patients, with a mean age of 65 years (range: 44–75 years), were reviewed at an average of 16 months (range: 4–18 months) after fracture fixation. The patients were assessed clinically, and radiographic evaluation of fracture healing, avascular necrosis and malunion was performed. Any complications of treatment were noted. All fractures united with no evidence of avascular necrosis. There was some varus deformity in two cases. There was one early loss of reduction but stability was re-established at re-exploration. Good or excellent clinical results were obtained in 10 patients according to the Constant score. Active abduction > 120° was achieved in 75% (nine patients). Paired suture fixation is an effective means of achieving stabilisation after open reduction of displaced two and three part proximal humeral fractures, with a low rate of non-union while preserving a good functional range of motion. The advantages of this technique are the minimal soft tissue stripping and the avoidance of complications associated with metalwork

Background:. Massive rotator cuff tear can cause functional disability due to instability and degenerative changes of the shoulder joint. In patients with massive irreparable rotator cuff tear, tendon transfer is often used as the salvage procedure. Latissimus dorsi and pectoris major transfer are technically demanding procedures and may incur complications. The biceps tendon transfer may provide a biologically superior tissue patch that improves the biomechanics of the shoulder joint in patients with irreparable rotator cuff tear. This study evaluated the functional outcomes of biceps tendon transfer for irreparable rotator cuff tear in 6 patients with two years and longer follow-up. Methods:. Between September 2006 and October 2011, 50 patients with 50 shoulders underwent surgical repair for MRI confirmed rotator cuff tear. Among them, six patients with massive irreparable rotator cuff tear were identified intraoperatively, and underwent proximal biceps tendon transfer to reconstruct the rotator cuff tear. The biceps tendon was tenodesed at the bicipital groove, and the proximal intra-articular portion of the biceps tendon was transected. The biceps graft was fanned out and the distal end fixed to the cancellous trough around the greater tuberosity with suture anchor. The anterior edge was sutured to the subscapularis and the posterior edge to the infraspinatus tendon or supraspinatus if present. Postoperative managements included sling protection and avoidance of strenuous exercises for 6 weeks, and then progressive rehabilitation until recovery. Results:. The evaluation parameters included VAS pain score, UCLA score, Constant score and AHES score, and X-rays of the shoulder. At follow-up of 25.3 ± 25.0 (range 22 to 63) months, the mean VAS pain score decreased from 9.3 ± 0.8 preoperatively to 1.7 ± 1.4 postoperatively (p < 0.001). All patients presented with significant improvements in pain and function of the shoulder for daily activities after surgery, however, only one patient achieved excellent results. There is no correlation of functional outcome with age, gender and body mass index. There was no infection or neurovascular complication. Discussion:. The biceps transfer provides soft tissue coverage of the humeral head, and restores the superior stability of the shoulder joint. The transferred biceps tendon also improves the mechanics and increases the compression force of the humeral head to the glenoid fossa. The results of the current study showed significant pain relief and improvement of shoulder function after biceps tendon transfer for irreparable rotator cuff tear. Conclusion:. Biceps tendon transfer is effective in the management of massive irreparable rotator cuff tear. The procedure is technically accessible with minimal surgical risks

Proximal humeral fractures are common and often occur in osteoporotic bone. Suture fixation utilises the rotator cuff tendons as well as bone providing adequate stability and avoids complications associated with metalwork insertion. Surgical exposure was via a delto-pectoral approach with minimal dissection of the fracture site. Initially a 2 suture technique was utilized with heavy ethibond sutures passed through drill holes either side of the bicipital groove; however, because of concerns about varus instability the technique now uses a third suture placed laterally acting as a tension band to prevent varus collapse. Patients with Neer 2 and 3 part fractures treated with suture fixation were assessed clinically (using the Constant score) and radiologically at a mean of 27 months post fracture. To date 24 patients have been studied. The average age of the patients in our series was 70.2. All fractures progressed to union with no cases of radiological avascular necrosis. We had 2 cases of mal-union (-one varus and one valgus-), both with a 2-suture technique. One patient had early loss of fixation; re-exploration was performed with stability conferred by a third lateral suture. Active abduction > 120o was achieved in 9 patients with a mean Constant score of 72 compared to 89 on the un-injured contra-lateral side. We have demonstrated that suture fixation of displaced proximal humeral fractures is an effective alternative to fixation using metalwork. The advantages are that minimal soft tissue stripping of the fracture site is required and the potential problems associated with metalwork insertion into osteoporotic bone are avoided. Following one case of varus mal-union with a 2-suture technique we now routinely use a third suture to act as a lateral tension band

The purpose of this study was to review the results of biceps tenodesis and biceps reinsertion in the treatment of type II SLAP lesions. We conducted a retrospective cohort study of a continuous series of patients. Only isolated type II SLAP lesions were included: twenty-five cases from January 2000 to April 2004. Exclusion criteria included associated instability, rotator cuff rupture and previous shoulder surgery. Ten patients (ten men) with an average age of thirty-seven years (range, 19–57) had a reinsertion of the long head of the biceps tendon (LHB) to the labrum with two suture anchors. Fifteen patients (nine men and six women) with an average age of fifty-two years (range, 28–64) underwent biceps tenodesis in the bicipital groove. All patients were reviewed by an independent examiner. In the reattachment group, the average follow-up was thirty-five months (range, 24–69); three patients underwent subsequent biceps tenodesis for persistent pain, three others were disappointed because of an inability to return to their previous level of sport, and the remaining four were very satisfied. The average Constant score improved from sixty-five to eighty-three points. In the tenodesis group, the average follow-up was thirty-four months (range, 24–68). No patient required revision surgery. Subjectively, one patient was disappointed (atypical residual pain), two were satisfied and twelve were very satisfied. All patients returned to their previous level of sports, and the average Constant score improved from fifty-nine to eighty-nine points. The results of labral reattachment were disappointing in comparison to biceps tenodesis. Thus, arthroscopic biceps tenodesis can be considered as an effective alternative to reattachment in the treatment of isolated type II SLAP lesions. By moving the origin of the biceps to an extra-articular position, we eliminated the traction on the superior labrum and the source of pain; furthermore, range of motion and strength are unaltered allowing for a return to a pre-surgical level of activity

Purpose: During surgery for repair of rotator cuff tears, some authors always associate tenotomy-tenodesis of the long head of the brachial biceps. Others decide as a function of the gross aspect of the tendon and its position in relation to the bicipital groove. It is a classical notion the preservation of the long head of the brachial biceps is a cuase of persistent pain in operated shoulders. This study was conducted to search for a histological validation of the decision to perform tenotomy. Material and methods: Fifty tendons of the long head of the brachial biceps presented a thick and inflammatory aspect with or without subluxation during 68 procedures to repair recent rotator cuff tears (23 men, 27 women, mean age 53.5 years). Tenodesis of the long head of the brachial biceps was associated with proximal tenotomy. The histological examination concerned the most proximal centimeter of the tendon. Four parameters were studied: two concerned the tendon (organisation of the collagen network and aspect of the interstitial connective tissue), two concerned the synovial border (sub-synoviocytic layer and synovial mesothelium). Sixteen tendons which appeared perfectly healthy were harvested from cadaver shoulders to determine the normal aspect of histological parameters (parallel and cohesive orientation of the collagen network, absence of hypertrophic interstitial connective tissue, thin subsynovio-cytic layer and pluristratified synovial mesothelium). Results: The tendon. The collagen bundles were oriented in 32 cases but thick in 40 and dissociated in 47. Microscopic signs of fissuration or intratendinous tears were present in 17 cases. The tendinous connective tissue was oedematous in 49 cases, presenting fibroblastic hyper-cellularity in 37 and hypervascularity in 43. Scar-like fibrosis was observed in 28 cases. The synovial layer was regular in 11 tendons and clearly thickened in 26 with a mixed irregular aspect in the others. The subsynoviocytic layer was thick in 33 tendons with signs of hypervascularity or hypercellularity in 12. The synovial mesothelium was paucistratifed in 23 cases, thick in 12, and regular in 15. Lesions had an inflammatory aspect and were intense in 26 cases. Degenerative lesions were observed in 21 tendons. These four histological parameters demonstrated that the lesions were advanced and associated with degenerative sclerosis with reactional synovitis in 30 cases, moderate combined lesions in 13, tendon and synovial inflammation alone in four, and advanced degenerative lesions of the tendon and the synovial in six. Discussion: Histological lesions of the long head of the brachial biceps tendon are generally degenerative and irreversible while most synovial lesions are reversible inflammatory reactions. The zones of intratendinous fibrosis, vascularity and weak or absent cellularity constitute the anatomic conditions before tendon tears in chronic tendinopathy. This histological study confirmed the validity of the intra-operative decision for tenodesistenotomy of the long head of the brachial biceps in 46 (92%) of the cases. The oedematous and fissu-rated aspect of the tendon appeared to be a reliable criteria while inflammatory synovitis, which surrounds the tendon, does not constitute in itself a formal argument in favour of tendon sacrifice

Aims

Fixation of osteoporotic proximal humerus fractures remains challenging even with state-of-the-art locking plates. Despite the demonstrated biomechanical benefit of screw tip augmentation with bone cement, the clinical findings have remained unclear, potentially as the optimal augmentation combinations are unknown. The aim of this study was to systematically evaluate the biomechanical benefits of the augmentation options in a humeral locking plate using finite element analysis (FEA).

Objectives

The long head of the biceps (LHB) is often resected in shoulder surgery and could therefore serve as a cell source for tissue engineering approaches in the shoulder. However, whether it represents a suitable cell source for regenerative approaches, both in the inflamed and non-inflamed states, remains unclear. In the present study, inflamed and native human LHBs were comparatively characterized for features of regeneration.