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Outcomes of the Biceps Suspension Procedure for Painful Inferior Glenohumeral Subluxation in Hemiplegic Patients
Surena Namdari, MD, MSc1; Mary Ann Keenan, MD1
1 Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Two Silverstein, Philadelphia, PA 19104. E-mail address for M.A. Keenan: maryann.keenan@uphs.upenn.edu
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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. One or more of the authors, or a member of his or her immediate family, received, in any one year, payments or other benefits of less than $10,000 or a commitment or agreement to provide such benefits from a commercial entity (McGraw-Hill Publishers).

Investigation performed at the Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania

Copyright © 2010 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2010 Nov 03;92(15):2589-2597. doi: 10.2106/JBJS.I.01390
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Patients with upper motor neuron injury can develop painful inferior glenohumeral subluxation with functional impairment. If the pain is relieved by manual reduction of the subluxation, this pain is considered mechanical in nature and potentially amenable to surgical treatment to maintain this reduction. The purpose of this study was to report our outcomes with use of the biceps suspension procedure to achieve shoulder joint reduction and pain relief in hemiplegic patients.


This retrospective case series of eleven consecutive hemiplegic patients with painful glenohumeral subluxation underwent surgical reduction with a biceps suspension procedure. Seven patients had, in addition, extra-articular tenotomies to treat coexisting muscular contractures. Pain, physical examination findings, and radiographs were evaluated before and after surgery. Patient satisfaction with the outcome of the surgery was determined as well.


The mean duration of the patient follow-up was 3.2 years (range, 2.0 to 5.8 years). The average patient age was 46.9 years (range, eighteen to eighty-one years). Ten of the patients were female. All patients had pain with passive shoulder motion preoperatively, but only one patient had such pain postoperatively (p < 0.001). At the time of follow-up after the surgery, the mean score for pain on a visual analog scale was 1.45 (range, 0 to 5), with all patients noting a decrease in pain. Ten patients noted that deformity was also decreased at the time of follow-up. All patients had a sulcus sign on physical examination preoperatively, but only three had such a sign postoperatively (p < 0.001). The seven patients who had undergone shoulder tenotomies had significant improvements in shoulder extension (p = 0.009), forward elevation (p = 0.030), abduction (p = 0.040), and external rotation (p = 0.043) postoperatively. Ten patients were satisfied with the outcome of the surgery. Preoperative radiographs demonstrated inferior subluxation of the humeral head at the glenohumeral joint in all patients. Postoperatively, ten patients had an improved glenohumeral joint position, and nine of these patients had complete reduction of the humeral head.


Biceps suspension surgery can provide pain relief in hemiplegic patients with painful subluxation of the humeral head after upper motor neuron injury. Tenotomy of contracted muscles around the shoulder can improve passive shoulder motion in patients with spastic hemiplegia. Following surgery, there were high rates of glenohumeral reduction and patient satisfaction.

Level of Evidence: 

Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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