11/15/2017. Biceps Lesions. Highgate Private Hospital (Whittington Health NHS Trust) E: LHB Anatomy.

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1 Biceps Lesions Mr Omar Haddo (Consultant Orthopaedic Surgeon MBBS, BmedSci, FRCS(Orth) ) Highgate Private Hospital (Whittington Health NHS Trust) E: admin@denovomedic.co.uk LHB Anatomy Arise from superior glenoid labrum and supraglenoid tubercle intra-articular and extraarticular portions Bicipital groove between lesser and greater tuberocity LHB Anatomy MCHL, SGHL and superior fibres of Subscapularis form a reflection pulley The transverse ligament 1

2 Anatomic variations Castanga et al J Shoulder Elbow Surg 2009 Jul-Aug;18(4): Variations of the intra-articular portion of the long head of the biceps tendon: a classification of embryologically explained variations 12 variations Kanatli et al Knee Surg Sports Traumatol Arthrosc Sep;19(9): Intra-articular variations of the long head of the biceps tendon. 7 variations LHB Function Lippmann likened the long head of the biceps to the appendix: an unimportant vestigial structure unless something goes wrong with it. Stabiliser of humeral head Head depressor flexor, abductor, and horizontal flexor of the shoulder (Itoi et al 2008). strongly influenced by the rotation of the humerus: ER -> abductor IR -> flexor Adduction and flexion (to 90) -> IR Abduction -> ER Proprioception Biceps activity increases with rotator cuff tears Physiology Thoracic frontal enlargement Scapula migration medial -> posterior Humeral head retroversion Medial migration of bicipital groove Actue curve of LHB over humerus 2

3 Pathology PAIN due to: SLAP lesions Tenosynovitis Hourglass tendon Partial to complete ruptures Biceps instability Asociated with: Rotator cuff tears Shoulder instabilities Diagnosis History & Examination Popeye sign 29 tests described Speed, Yergason, O Brien s, Crank and Biceps Load tests Imaging Arthroscopy Ramp test SLAP lesions Superior Labrum Anterior-Posterior tear Forceful traction (+/- dislocation), fall with forced superior force, repeated overhead activity Common in athletes 3

4 SLAP lesions Intrarticular LHB Watershed area Biceps anchor SLAP lesions History Trauma Painful clicking Pain on loading of biceps Investigations MR arthrogram SLAP lesions 4

5 SLAP lesions Treatment: Analgesia, physio & activity modification Surgery Type I debridement Type II repair Type III excise &? repair Type IV -? repair excise & tenodesis Better outcome: Younger pts Single traumatic event Non-overhead sports Tenosynovitis Treatment usually nonoperative Steroid injection Arthroscopy/probing confirms reactive but intact/stable biceps Subacromial decompression Tenotomy / tenodesis 5

6 Hourglass LHB Hypertrophic intraarticular portion of the tendon Unable to slide into the bicipital groove during elevation Arthroscopic diagnosis Biceps tenotomy or tenodesis with excision of the intraarticular portion of the LHB tendon J Shoulder Elbow Surg May-Jun;13(3): Entrapment of the long head of the biceps tendon: the hourglass biceps--a cause of pain and locking of the shoulder. Boileau P, Ahrens PM, Hatzidakis AM Partial tear Uncommon as an isolated lesion Rotator cuff pathology usually present Carefully assess for biceps instability Surgery: Biceps debridement in <50% (30% in younger/labourers) Tenotomy Tenodesis Biceps instability Isolated biceps instability Transverse humeral ligament tear Often associated with subscapularis or supraspinatus tear Surgery: Stabilization Difficult to perform (open or arthroscopic) Recurrent instability a concern Stenosed, painful biceps may result Tenotomy Tenodesis 6

7 Tenotomy vs Tendonitis Tenotomy good functional results (Gill et al J Shoulder Elbow Surg 2001) Weakness, cramping and cosmesis (Wolf et al. Arthroscopy 2005) Tenodesis Preserve and restore length of LHB Avoid scarring Avoid muscle cramp Preserve biceps function for complex motion of elbow cosmetics Tenotomy vs Tenodesis Tenodesis Cost Longer surgery Pain Post op immobilisation literature suggests that a simple biceps tenotomy may be considered in individuals older than 50 years provided that they have been counselled regarding the risk of cosmetic deformity. Tenodesis Proximal near the articular cartilage At the groove Suprapectoral Subpectoral 7

8 Distal Biceps Singular flat structure Insert to ulna aspect of radial tuberocity Normal variant in 40 60% (2 tendonous insertions) Lacertus fibrosus aponeurosis encompassing the biceps tendon Extend into forearm fascia Distal Biceps rupture Spectrum of disease tendinitis partial-thickness ruptures complete ruptures Excessive eccentric load applied to a previously flexed elbow avulsion of the distal tendon stump from the bicipital tuberosity Distal Biceps rupture Common in: dominant arm (86%) men thirty to fifty corticosteroid and tobacco Predisposing factors: physiological ischemia potential focal osseous irregularities of the radial tuberosity oblique biomechanical force exerted by medial translation of the lacertus fibrosus during flexion of pronated forearm 8

9 Diagosis Tendinitis/partial tear deep antecubital pain exacerbated by resisted supination Complete tear Acute: pain, weakness, ecchymosis, reverse Popeye Chronic: supination weakness, reverse Popeye Hook test O Driscoll Treatment Non-operative 30% reductions in flexion and 40% supination strength Operative Single vs double incision techniques Questions? 9

10 Thank you Mr Omar Haddo (Consultant Orthopaedic Surgeon MBBS, BmedSci, FRCS(Orth) ) E: admin@denovomedic.co.uk 10