Abstract
Background: Tears of the subscapularis tendon commonly are
associated with instability of the long head of the biceps tendon. Standard
surgical treatment includes tenodesis or tenotomy of the biceps tendon.
However, chronic discomfort from spasms and cosmetic disadvantages have been
reported following both procedures, while the potential for functional
impairments remains controversial. We investigated the outcome of
stabilization of the long head of the biceps tendon in the context of early
repair of traumatic tears of the subscapularis tendon.
Methods: We performed stabilization of an unstable, structurally
intact long head of the biceps tendon in twenty-one patients in the acute
phase after a traumatic tear of the subscapularis tendon. The average period
from the injury to the surgery was 6.2 weeks. Open tendon stabilization and
subscapularis reconstruction were performed with transosseous sutures. The
follow-up consisted of clinical examination (with determination of the
absolute, age and genderrelated, and individual relative Constant scores;
clinical evaluation of the long head of the biceps; and subjective
determination of shoulder function) and dynamic ultrasound examination.
Results: The average follow-up period was 28.4 months. The mean
absolute Constant score increased from 26.3 points preoperatively to 79.3
points postoperatively (p < 0.01). The mean age and gender-related Constant
score improved from 28.0% to 87.0% (p < 0.01). Seven patients showed
clinical symptoms consistent with mild biceps tendinopathy. Using dynamic
ultrasound examination, we found two cases of recurrent instability (medial
subluxation) of the long head of the biceps tendon. Secondary rupture of the
long head of the biceps tendon occurred in one patient, twenty-six months
after the surgery.
Conclusions: The functional outcomes of stabilization of the long
head of the biceps tendon in the context of early repair of a traumatic tear
of the subscapularis tendon were comparable with the results of tenodesis or
tenotomy reported in previous studies. The cosmetic results were superior, and
chronic discomfort from spasms was not observed. Stabilization of the tendon
of the long head of the biceps can be recommended as a treatment option for
selected patients and should be discussed as an alternative to tenodesis or
tenotomy, particularly in a young patient.
Level of Evidence: Therapeutic Level IV. See Instructions
to Authors for a complete description of levels of evidence.
Tears of the subscapularis tendon commonly are associated with instability
of the long head of the biceps tendon. Edwards et
al.1 found
instability (subluxation or dislocation) of the long head of the biceps tendon
in fifty-four of eighty-four patients in whom an isolated eyp of the
subscapularis tendon was seen intraoperatively. Nove-Josserand et
al.2 observed
subluxation or dislocation of the long head of the biceps tendon in ten of
sixteen patients with an isolated subscapularis lesion. Gerber et
al.3,4
found pathology of the long head of the biceps tendon in twelve of sixteen
patients with an isolated traumatic tear of the subscapularis tendon; four of
the sixteen had a medial dislocation of the tendon. Deutsch et
al.5 reported biceps
tendon subluxation, dislocation, or rupture in seven of fourteen patients with
a traumatic tear of the subscapularis tendon.
Trauma has been described as a major cause of sub-scapularis tendon tears
in the
literature1-5.
Fifty-seven of eighty-four patients, in what we believe is the largest
reported series of subscapularis tendon tears, had had a specific traumatic
episode1. Eighteen
patients had had a primary traumatic anterior-inferior dislocation of the
shoulder. Gerber et
al.3, who specified
traumatic mechanisms that can cause subscapularis tendon tears, described
hyperextension or external rotation of the abducted arm as the mechanism in
ten of thirteen patients. Early surgical repair is the treatment of choice for
traumatic tears of the subscapularis
tendon1,6,7.
The clinical results after tenodesis of the long head of the biceps tendon
can be compromised by persistent biceps tenderness or secondary failure of the
tenodesis8-10.
Berlemann and
Bayley9 described
unsatisfactory long-term results in six of fourteen patients after keyhole
tenodesis. In another series, discomfort from spasms and soreness of the
biceps muscle were the primary problems in fifteen of forty patients who had
had an arthroscopic tenotomy of the long head of the biceps
tendon11. All of
these patients were sixty years of age or younger. Tenotomy can also have
cosmetic
disadvantages11-13.
Clinically apparent distal migration of the biceps muscle (the Popeye sign) is
common after tenotomy of the long head of the biceps
tendon11,12.
Kelly et al.11
reported a positive Popeye sign in twenty-four of twenty-nine men and four of
eleven women.
We found the long head of the biceps tendon to be unstable but structurally
intact in some patients when we under-took early repair of a traumatic tear of
the subscapularis tendon. Considering the importance of the long head of the
biceps tendon and the risks of chronic discomfort from spasms and an
unsatisfactory cosmetic appearance following tenotomy or tenodesis, we
hypothesized that these patients may benefit from stabilization and
preservation of the structurally intact long head of the biceps tendon. The
purpose of this prospective study was to demonstrate the feasibility of
stabilization of the long head of the biceps tendon in the context of early
repair of a traumatic tear of the subscapularis tendon and to investigate the
clinical and radiographic outcomes after open anatomic reconstruction. Special
attention was paid to the evaluation of the stability as well as the clinical
function of the long head of the biceps tendon postoperatively.
We performed a stabilization of the long head of the biceps tendon, in the
acute phase after the injury, in twenty-one patients (five female and sixteen
male) who had instability of the long head of the biceps tendon and a
traumatic tear of the subscapularis tendon. The mean age was fifty-one years
(range, thirty to seventy years) at the time of surgery. All patients had a
history of a specific injury to the shoulder joint that was appropriate for
the injury that they had sustained; there were seventeen falls on the abducted
and externally rotated arm and four primary traumatic anteriorinferior
dislocations of the shoulder. There was no history of shoulder pain or other
shoulder abnormalities prior to the injury. Preoperative true anteroposterior
and supraspinatus outlet radiographs were made to exclude the possibility of a
fracture. Magnetic resonance imaging as well as dynamic ultrasound
examinations were performed in internal, neutral, and maximum external
rotation. Inclusion criteria were provision of written informed consent by the
patient, intraoperatively proven instability of the macroscopically intact
long head of the biceps tendon, complete reconstruction of the torn
subscapularis tendon, and a minimum follow-up period of twenty-four months.
Exclusion criteria were the absence of a history of adequate trauma to cause
the injury, macroscopic signs of pathological changes (rupture, degeneration,
inflammation, or thickening) in the long head of the biceps tendon at the time
of surgery, a posterior tear of the rotator cuff, atrophy of the subscapularis
muscle demonstrated on the preoperative magnetic resonance imaging
scan14, and a
period of more than ten weeks since the time of injury.
The average period from the injury to the surgery was 6.2 weeks (range,
three to nine weeks). All patients were evaluated preoperatively on the basis
of the original (absolute) version of the Constant
score15. The
absolute Constant score was then related to age and gender to obtain a
relative Constant score, which was expressed as a percentage of the respective
reference values reported by
Constant16. We also
determined the individual relative Constant score as proposed by Fialka et
al.17. The
subjective shoulder function was determined with use of the single-assessment
numeric evaluation
method18. The
patients rated the subjective function of both shoulders on a scale ranging
from 0% to 100% (normal shoulder function) preoperatively. An independent
observer assessed the cosmetic appearance of the biceps muscle and classified
the Popeye sign as negative, mild, moderate, or distinct.
Surgical Technique
The patient was placed in the beach-chair position. A deltopectoral
approach was used to identify the bicipital groove. The rotator interval was
found to be ruptured in all patients. In the caseS of a smaller tear (four
patients), the interval was opened about 2 cm in a longitudinal direction,
starting at the superior-medial edge of the bicipital groove. The long head of
the biceps tendon was identified, and instability of this structure was
classified, with a system established for the purpose of this study, as B1 (in
place but medially unstable), B2 (medial subluxation), or B3 (medial
dislocation). B1 instability was detected with hook probe examination. We
found B1 instability in three patients (14%), B2 instability in six (29%), and
B3 instability in twelve (57%). The medial branch of the coracohumeral
ligament and the superior glenohumeral ligament were ruptured in all patients.
The long head of the biceps tendon was repositioned into the bicipital groove
(Fig. 1, a). The tears
of the subscapularis tendon were classified, also with a system established
for the purpose of this study, as S1 (involving the superior 25% of the
tendon), S2 (superior 50%), S3 (superior 75%), or S4 (100%). All of the
dislocations of the long head of the biceps tendon occurred into or under the
subscapularis tendon. We found eight S1 tears (38%), eight S2 tears (38%),
three S3 tears (14%), and two S4 tears (10%). Two holding stitches with
number-1 PDS (polydioxanone) suture (Johnson and Johnson International,
St-Stevens-Woluwe, Belgium) were placed into the lateral aspect of the
subscapularis tendon, and the remaining tendon was released directly at its
insertion into the lesser tuberosity. The tendon was released in a medial
direction. The cortex of the lesser tuberosity was roughened medial to the
bicipital groove line. A semicircular drill hole was then placed in the bone
right next to the medial edge of the bicipital groove with a CurvTek device
(Arthrotek, Warsaw, Indiana). The hole was placed in a longitudinal
orientation parallel to the bicipital groove line with the superior hole
located directly at the superior-medial edge of the bicipital groove. Another
drill hole was placed in a parallel orientation approximately 1 cm medial to
the first one. A number-1 PDS suture was guided through the lateral drill
hole, and a longitudinally oriented inside-out u-stitch was placed into the
lateral border of the subscapularis tendon. The superior suture end was then
passed through the medial branch of the coracohumeral ligament and the
superior glenohumeral ligament. Another number-1 PDS suture was then guided
through the medial drill hole, and another inside-out u-stitch was placed in a
parallel orientation approximately 1 cm medial to the first one
(Fig. 2). This technique
resulted in a stable four-point refixation of the subscapularis tendon and
simultaneous reconstruction of the biceps reflection pulley. The stability of
the long head of the biceps tendon was verified by hook probe examination and
examination of the passive range of motion. Special care was taken to ensure
free gliding of the long head of the biceps tendon in order to avoid creating
a tenodesis. In the case of a tear of the anterior aspect of the supraspinatus
tendon (three patients), we roughened the cortex at its insertion on the
greater tuberosity. A semicircular drill hole was placed in an
obliquehorizontal orientation with the medial hole located directly at the
superior-lateral edge of the bicipital groove. A number-1 PDS suture was
guided through the drill hole, and an inside-out u-stitch was placed into the
supraspinatus tendon. The medial suture end was also passed through the
lateral branch of the coracohumeral ligament
(Fig. 2). Both the rotator
interval and the transverse humeral ligament were reconstructed with number-1
or 0 PDS simple sutures.
Postoperative Care
Postoperatively, the arm was placed in a 15° abduction splint, which
was worn for six weeks during the day and night. Passive mobilization was
initiated on the first postoperative day with the aid of a physiotherapist.
Active-assisted external rotation was started on the basis of the amount of
the intraoperative range of motion and was adapted individually according to
the amount of pain and tension. The limit was set at neutral for active and
passive external rotation. Active internal rotation, elbow flexion, and
forearm supination were restricted for six weeks. Otherwise, the passive
ranges of motion of the glenohumeral and elbow joints were not restricted.
After six weeks, a free active and passive range of motion was allowed, and
the patients started light isometric exercises. The patients did not perform
intense weight-lifting exercises or overhead sport activities for three
months. The patients returned to full physical and sports activity at three
months after the surgery.
Follow-up Assessment
An independent observer performed the clinical and sonographic follow-up
examinations as well as the assessment of the Constant scores. The patients
rated subjective shoulder function with use of the single-assessment numeric
evaluation
method18, and the
function of the long head of the biceps tendon was examined clinically with
the palm-up test and the Yergason test. The Popeye sign was used to describe
the cosmetic appearance of the biceps muscle. The stability of the long head
of the biceps tendon was assessed with dynamic ultrasound examinations at six
and twelve weeks and at the time of the last follow-up.
Prism 4.0 for Macintosh (GraphPad Software, San Diego, California) was used
for statistical analysis. A paired-sample t test was used for the evaluation
of the preoperative and postoperative scores. A Wilcoxon matched-pairs test
and a Pearson correlation test were used for statistical comparison of the
clinical outcome parameters. A Mann-Whitney test was used to compare the
clinical outcome of the younger patient group (thirty to fifty years old, n =
11) with the outcome of the older patient group (fifty-one to seventy years
old, n = 10). The level of significance was set at p < 0.05.
The average follow-up period was 28.4 months (range, twenty-four to
fifty-four months). We observed relevant postoperative complications in three
patients (14%). Medial subluxation of the long head of the biceps tendon was
suspected clinically in two patients (10%), both of whom originally had had a
medial dislocation of the long head of the biceps tendon. The subluxation of
the long head of the biceps tendon was diagnosed with use of dynamic
ultrasonography and magnetic resonance imaging in one patient. In the other
patient, the instability was detectable only with dynamic ultrasonography; a
magnetic resonance imaging scan in neutral rotation did not show any signs of
the displacement of the long head of the biceps tendon. A rerupture of the
superior half of the subscapularis tendon was found in both patients (one
patient originally had had a tear of the superior 75% of the tendon, and the
other had had a complete tear). These two patients were substantially older
(sixty-eight and seventy years of age) than the average age of the patient
population. There was no history of trauma during the postoperative
rehabilitation period in either patient. The two patients did not wish to
undergo revision surgery because they were satisfied with the clinical
outcome.
Secondary rupture of the long head of the biceps tendon was found in one
patient twenty-six months after the surgery. This patient originally had had a
medial dislocation of the long head of the biceps tendon and a tear of the
superior 50% of the subscapularis tendon. The postoperative rehabilitation was
complicated by shoulder stiffness in this patient. There were no signs of
instability of the long head of the biceps tendon or rerupture of the
subscapularis tendon clinically or on magnetic resonance imaging or dynamic
ultrasonography. Two months after the surgery, the magnetic resonance imaging
scan showed thickening of the anterior aspect of the capsule and increased
signal intensity (on T2-weighted axial images) in the rotator interval
consistent with a nonspecific inflammatory process. However, the magnetic
resonance imaging assessment was limited as a result of artifacts caused by
the PDS material. Clinically and serologically, there were no signs of
infection. The patient was successfully treated with temporary use of oral
nonsteroidal anti-inflammatory medication and pain-adapted physiotherapy.
Figure 3 shows the
preoperative and postoperative Constant scores. All Constant scores (absolute,
relative, and individual relative) improved significantly (p < 0.01). The
mean absolute Constant score (and standard deviation) improved from 26.3
± 12.8 points (range, 12 to 51 points) to 79.3 ± 13.9 points
(range, 62 to 94 points). The mean relative Constant score (age and
gender-related) improved from 28.0% ± 12.1% (range, 13% to 52%) to
87.0% ± 21.3% (range, 61% to 117%). The mean individual relative
Constant score improved from 24.1% ± 11.6% (range, 12% to 48%) to 73.6%
± 13.1% (range, 56% to 90%). There was a significant correlation
between the mean postoperative absolute Constant score and the mean individual
relative Constant score (r = 0.93, p < 0.01) as well as between the mean
relative Constant score and the mean individual relative Constant score (r =
0.83, p < 0.05). With the numbers studied, we could not find a significant
difference in the postoperative mean absolute, relative, or individual
relative Constant score between the younger and older patient groups.
Subjective shoulder function significantly improved from a mean of 18.8%
± 8.3% (range, 10% to 30%) preoperatively to a mean of 80.0% ±
10.7% (range, 65% to 100%) postoperatively (p < 0.01). The mean
postoperative subjective shoulder function did not correlate with the mean
postoperative absolute, relative, or individual relative Constant score.
Preoperatively, all patients had positive palm-up and Yergason tests. At
the time of the last follow-up examination, these tests were positive for
seven patients (33%), including the two with medial subluxation of the long
head of the biceps tendon and rerupture of the superior half of the
subscapularis tendon. The clinical symptoms were consistent with mild biceps
tendinopathy. Clinical examination, magnetic resonance imaging, and dynamic
ultrasonography showed no signs of instability of the long head of the biceps
tendon or rerupture of the subscapularis tendon in these five patients. None
of the five wished to undergo additional surgical treatment because they were
satisfied with the clinical result. Preoperatively, a positive Popeye sign
(mild) was found in nine patients (43%), all of whom had had a medial
dislocation of the long head of the biceps tendon intraoperatively. At the
time of the last follow-up examination, only the patient with the secondary
rupture of the long head of the biceps tendon had a positive (distinct) Popeye
sign.
Dynamic ultrasonography showed the position of the long head of the biceps
tendon to be normal in all patients except for the two in whom it demonstrated
the medial subluxation of the long head of the biceps tendon. As mentioned,
these two patients also had a rerupture of the superior half of the
subscapularis tendon. The medial subluxation of the long head of the biceps
tendon was present with maximum passive external rotation.
Secondary rupture of the long head of the biceps tendon occurred in one
patient twenty-six months after the surgery.
To our knowledge, the clinical and radiographic results of stabilization of
the long head of the biceps tendon in the context of a repair of a traumatic
tear of the subscapularis tendon have not been reported previously. Edwards et
al.1 performed
stabilization of the long head of the biceps tendon in selected patients.
However, the postoperative course was prolonged, and the overall clinical
results were unsatisfactory. These poor results may have been related in part
to deepening of the bicipital groove at the time of stabilization.
Werner et al.19
analyzed the rotator interval and the biceps reflection pulley
histoanatomically. The superior glenohumeral ligament and parts of the
"fasciculus obliquus" were identified as the main stabilizers of
the long head of the biceps tendon. The fiber orientation suggests that these
structures mediate the absorption of anterior shear stresses. Recently,
Gleason et al.20
performed a histoanatomical examination of the so-called transverse humeral
ligament. While a specific ligamentous structure could not be identified, the
structure appears to consist of fibers of the subscapularis and supraspinatus
tendons accompanied by parts of the medial coracohumeral ligament. Slatis and
Aalto21
demonstrated that the medial coracohumeral ligament is the key ligament that
prevents the long head of the biceps tendon from dislocating medially. These
anatomic findings suggest that the reconstruction of the subscapularis tendon
(particularly of its superiorlateral border) and the coracohumeral ligament
was an important factor in the achievement of effective stabilization of the
long head of the biceps tendon in our series. The two sonographically proven
cases of postoperative medial subluxation of the long head of the biceps
tendon were associated with a rerupture of the superior half of the
subscapularis tendon. We were not able to determine whether the rerupture
preceded the instability of the long head of the biceps tendon or vice versa.
In this small series, however, we did not observe either isolated instability
of the long head of the biceps tendon or isolated rerupture of the
subscapularis tendon. Medial dislocation of the long head of the biceps tendon
appears to require failure of the medial and anterior stabilizers. We presume
that rerupture of the subscapularis tendon led to the medial subluxation of
the long head of the biceps tendon in these two patients. However, we cannot
address the question of whether a tendency toward subluxation of the biceps
may have played a role in the subsequent subscapularis rerupture.
Edwards et al.1
reported a mean absolute Constant score of 79.5 points after open
reconstruction of torn subscapularis tendons. Gerber et
al.4 found a mean
relative Constant score of 82% after open repair of traumatic tears of the
subscapularis tendon. Kreuz et
al.22 reported on
thirty-four patients with a traumatic tear of the subscapularis tendon,
eighteen of whom also had a tear of the supraspinatus tendon. The mean
absolute Constant score increased from 43.9 points preoperatively to 88.7
points postoperatively in the patients with an isolated tear and from 40.6 to
74.7 points in those with combined tears. In our series, the mean absolute
Constant score improved from 26.3 to 79.3 points; the mean relative Constant
score, from 28.0% to 87.0%; and the mean individual relative Constant score,
from 24.1% to 73.6%. Finally, subjective shoulder function increased from
18.8% to 80.0%. The functional outcomes in our series are comparable with
those in previous studies that did not incorporate stabilization of the long
head of the biceps tendon with the subscapularis tendon repair. However, the
cosmetic results in our series were
superior1, and our
patients did not report chronic discomfort from spasms.
Although the Constant score does not fully reflect shoulder functions
related to the long head of the biceps tendon, it was important to interpret
our results in the context of those in previous studies. Our investigations
were supplemented by clinical examinations of the function of the long head of
the biceps tendon as well as by dynamic ultrasound examinations. We know of no
other reports on the clinical results of procedures combining stabilization of
the long head of the biceps tendon and repair of a tear of the subscapularis
tendon. Future comparative studies are necessary to investigate other
potential benefits of the procedure. Also, more specific tests of shoulder
functions related to the long head of the biceps tendon should be included.
Potential complications of stabilization of the long head of the biceps tendon
are biceps tendinopathy and recurrent instability or rupture of the long head
of the biceps tendon. Furthermore, persistent or recurrent instability of the
long head of the biceps tendon may result in rerupture of the subscapularis
tendon. We recommend regular clinical and sonographic follow-up examinations
for symptomatic patients, who may require further surgical management,
including secondary tenodesis or tenotomy of the long head of the biceps
tendon8,11,12,23,24.
We only included patients with a traumatic lesion that had undergone early
surgical repair. It is well known that time is an important prognostic factor
affecting the results of reconstructions of rotator cuff
tears25. Delayed
stabilization of the long head of the biceps tendon could be associated with a
higher prevalence of postoperative complications related to that structure
(tendinopathy and secondary rupture). It should be emphasized that this
technique is applicable only in selected cases. The long head of the biceps
tendon was stabilized in only twenty-one of 403 patients who underwent open
reconstruction of the rotator cuff during the study period. Tears of a
primarily degenerative origin are far more common than are purely traumatic
tears of the subscapularis tendon. Also, degenerative and/or chronic tears are
often associated with pathological conditions of the long head of the biceps
tendon other than instability, such as inflammation, degeneration, or
fibrillation. Tenodesis or tenotomy has to be regarded as the standard
surgical treatment for such cases.
With the small numbers studied, age did not appear to influence the
postoperative outcome. However, the two patients with a rerupture of the
subscapularis tendon were substantially older than the average age of the
study population. Consequently, age has to be considered as an exclusion
criterion for this procedure. There was a strong correlation among all of the
versions of the Constant score (absolute, relative, and individual relative),
whereas subjective shoulder function did not correlate with the Constant
scores. A reason for this might be that subjective shoulder function depends
strongly on individual demands. However, this measure may provide important
information about the patient's assessment of the postoperative result.
In conclusion, our results suggest that stabilization of a structurally
intact long head of the biceps tendon is a viable treatment option in the
context of early repair of a traumatic tear of the subscapularis tendon. This
treatment option should be considered for selected patients as an alternative
to tenodesis or tenotomy of the long head of the biceps tendon. ?
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