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Long head of the biceps tendon rupture in professional wrestlers: treatment with a mini-open tenodesis
J Shoulder Elbow Surg (2011) 20, 409-413
www.elsevier.com/locate/ymse
Long head of the biceps tendon rupture in professional wrestlers: treatment with a mini-open tenodesis Mario Tangari, MDa, Stefano Carbone, MDb,*, Mimmo Gallo, MDc, Andrea Campi, MDc a
Department of Hand Surgery, ‘‘S. Giovanni-Addolorata’’ Hospital, Via dell’Amba Aradam, Rome, Italy Department of Orthopaedic and Traumatology, University of Rome ‘‘Sapienza’’, P.le Aldo Moro, 5, Rome, Italy c Department of Orthopaedic and Traumatology, ‘‘S. Giovanni-Addolorata’’ Hospital, Via dell’Amba Aradam, Rome, Italy b
Background: The aim of this study is to assess the validity of a mini-open tenodesis of the long head of the biceps tendon (LHBT) performed on 5 professional wrestlers injured while fighting. Methods: Five professional wrestlers with an acute rupture of the LHBT were treated with a mini-open tenodesis procedure without arthroscopic assistance. This technique is performed with 2 miniscule incisions of the skin. The tendon is prepared with biological fibrin glue and with a No. 2 Fiberwire; after that, the tendon is sutured to the bicipital groove with a suture anchor. At the follow-up exam (average 7.6 years; range, 2-13), clinical assessments were obtained with the Constant score (CS) and Mayo Elbow Performance Score (MEPS). Forearm flexion strength was measured with a dynamometer, and a magnetic resonance image was also obtained. Results: At the follow-up, the average age of the patients was 32.6 years (range, 28-40). The average CS of the involved shoulder was 95 points (range, 92-98), compared to 97 points (range, 94-98) of the contralateral side (P ¼ .37). The MEPS was 99.76 for the elbow of the involved side and 99.84 for the contralateral one (P ¼ .34). No significant difference was noted for the forearm flexion strength (P ¼ .31). Discussion: In this study, patients were all high-demand wrestlers and biceps tenodesis was mandatory. Mini-opening without arthroscopic assistance tenodesis of the long head of the bicep tendon to the bicipital groove has been used for these professional wrestlers. Functional and cosmetic results of this technique have been excellent, and it allowed athletes to return shortly to their sport activity. Level of evidence: Level IV, Case Series, Treatment Study. Ó 2011 Journal of Shoulder and Elbow Surgery Board of Trustees. Keywords: Biceps tenodesis; mini-open tenodesis; long head of the biceps tendon rupture; wrestlers
Rupture of the long head of the biceps tendon (LHBT) is a common tendon injury, and, according to Gilcreest,12 it represents 90% of biceps ruptures. He also noted that an acute, traumatic rupture of this tendon occurs most often when a person is raising a weight of 68 kg or more. Otherwise, ruptures of the LHBT are commonly caused by *Reprint requests: Stefano Carbone, MD, University of Rome, ‘‘Sapienza’’, P.le Aldo Moro, 5, Rome, Italy. E-mail address: [email protected] (S. Carbone).
degenerative changes within the tendon and are associated with pathologies of the subacromial space. LHBT pathology ranges from simple cases of tendonitis to more complex pathologies such as tendon instability (subluxation or dislocation) and rupture (partial or complete). The common site of rupture occurs within the bicipital groove; this predominantly occurs in men in their 6th or 7th decade of life as a result of the weakening of the tendon by degenerative process.19 Less commonly, ruptures have been reported in weight lifters at the musculotendinous junction
1058-2746/$ - see front matter Ó 2011 Journal of Shoulder and Elbow Surgery Board of Trustees. doi:10.1016/j.jse.2010.08.008
410 and within the muscle belly.5 Recently, the diagnosis and treatment of a 36-year-old man who sustained a proximal biceps rupture while arm wrestling and his operative management have been described;18 in addition, there is a report of an isolated LHBT rupture in an underhand thrower, as a result of the increased bicep muscle activity or increased tendon excursion in the windmill-pitching motion.9 While nonoperative treatment is often successful, operative treatment may be required for those patients who do not achieve acceptable pain control or functional recovery. Furthermore, surgical repair is recommended for acute ruptures in those patients with high demands and in whom slight loss of flexion and supination strength is not well tolerated. Biceps tenodesis is the most commonly performed procedure for biceps tendon rupture.10,11 Numerous surgical techniques of tenodesis have been advocated; however, many of these require moving the biceps tendon to the coracoid process with undue medial dissection followed by prolonged restriction of shoulder and elbow movement with substantial morbidity.11,13 Keyhole tenodesis was introduced to overcome these inadequacies, with the tendon attached to the bone which permits immediate mobilization.5 Fixation of the tendon to the bone with interference screw has been used by some authors, combining this technique to the arthroscopic surgery.1,2 Other authors have combined the arthroscopic with percutaneous, intra-articular trans-tendon technique or with miniopen tenodesis.20,24 The mini-open approach to the tendon rupture and tenodesis without arthroscopic assistance has been described by Burkhead in 1990.3 We have adopted this mini-open technique for 5 professional wrestlers, using 1 suture anchor applied to the bicipital groove with 2 miniincisions of the skin (2 cm), 1 to get to the tendon stump, and the other to suture the tendon to the bone.
Materials and method Between 1997 and 2008, 5 professional wrestlers were referred to our hospital after they experienced a snap and shoulder pain while fighting in the gym. They were seen by 1 of the authors after a average time of 3 days (range, 1-10). Preoperative diagnosis was made by clinical examination, based on the presence of the classic Popeye sign or a less striking descent of the biceps muscle in the middle part of the arm; a magnetic resonance image was obtained in all cases to confirm the diagnosis and to exclude other lesions of the gleno-humeral joint. They all denied having used anabolic steroids. The surgical procedure is performed in the beach-chair position. The arm is positioned adducted to the body, in neutral rotation and with about 20 of extension for a better visualization of the humeral head and bicipital groove. All biceps tendon tears in this study were extra-articular and did extend to the bicipital groove. With the ultrasound probe (7,5 GHz), the exact localization of the tendon stump is obtained and then marked with a surgical pen. Maintaining the arm in the same position, with ultra-sound control, the bicipital groove is located and marked. In correspondence of the 2 marked areas,
M. Tangari et al.
Figure 1
The mini-incision of the skin to get to the tendon stump.
a 2-cm skin incision is made (Figure 1). The tendon stump is felt under the finger, the brachialis fascia covering the biceps is then opened, and the biceps tendon is retrieved out of the wound (Figure 2). To ensure appropriate tensioning of the biceps tendon, the proximal portion of the tendon is resected to leave 20-25 mm of tendon proximal to the musculotendinous portion of the biceps.15 Using a Krackow or whip-stich, a No. 2 Fiberwire (Arthrex, Naples, FL) nonabsorbable suture is weaved into the proximal 15 mm of tendon. To obtain faster healing of the tendon to the bone, in all but 1 patient, the LHBT is prepared with biological fibrin glue (Tissucolâ, Baxter) (Figure 3). A suture passer is inserted in the superior skin incision and it is guided under the brachialis fascia until the second incision. Subsequently, the tendon stump is tied to the suture passer and the last is pulled upward to the superior incision. The bone in the area of the upper portion of the bicipital groove is prepared using a burr until bleeding. Then, a 5-mm suture anchor (Arthrex) is inserted in the upper reachable (from the skin incision) portion of the bicipital groove. The sutures from the tendon stump are then tied to those of the anchor and the knots tightened with an arthroscopic suture passer (surgical technique illustrated in Figures 4, A-C). After surgery, a sling is applied for 7 days and then self-assisted recovery of range of motion is allowed. Flexion of the elbow and supination of the hand against resistance is forbidden for 2 months; finally, all the professional athletes returned to their full activities. At follow-up (average time, 7.6 years; range, 2-13), objective evaluation of the shoulder and the elbow was obtained with the Constant score (CS)4 and the Mayo Elbow Performance Score (MEPS).16 Flexion strength of the forearm (with the forearm flexed at 90 and the arm adducted to the body, with the hand in full supination) (1 point ¼ 1 lb) was measured with the use of the MicroFET dynamometer (Hoggan Health Industries, West Jordan, UT). Finally, an MRI was also obtained. The differences of the CS, MEPS, and the flexion strength of the forearm between the involved and contralateral sides were analyzed with the Chi-square test. P < .05 was considered to be significant.
Results The average age at the time of injury was 25.4 years (range, 2327) and the right shoulder was involved in 5 cases. At the followup, the mean age of the patients was 32.6 years (range, 28-40).
Biceps tendon tenodesis in professional wrestlers
Figure 2
The biceps tendon is retrieved out of the wound.
After the operation, we did not observe any complications. At follow-up, the mean CS of the involved shoulder was 95 points (range, 92-98), compared to 97 points (range, 94-98) on the contralateral side (P ¼ 0.37). The range of motion was similar in the 2 shoulders. Mean flexion strength of the forearm result was 42 points (range, 38-50) on the affected side (dominant side) and 40 on the contralateral one (range, 38-46) (P ¼ .31). The MEPS was 99.76 for the elbow of the involved side and 99.84 for the contralateral one (P ¼ .34). On MRI scans of all patients, the long head of the biceps appeared thickened and healed to the bicipital groove; in 2 of the 5 athletes (40%), a Bankart lesion was noted with a concomitant Hill-Sachs of the humeral head. Despite these MRI findings, all the shoulders were clinically stable. Cosmesis of the arm was judged as excellent in all cases, both by the patients and the surgeon (Figure 5). At an average of 5 months (range, 3-7) after surgery, all the wrestlers had returned to their professional sport activity, and 4 of the 5 are still professional wrestlers.
Discussion There is controversy in the literature regarding treatment of ruptures of the long head of the biceps (LHB). Most agree that surgical correction is usually not necessary and nonsurgical therapy has been advocated by many. For example, Turek21 stated that ‘‘the operation is contraindicated except in the young individual for vigorous occupations or sports or for cosmesis. It should never be performed in the elderly or persons with light activities.’’ In this study, the patients were all high-demanding wrestlers; all were aged around 25 years, considerably younger than the usual age of presentation of ruptures of the LHB. All of them were highly concerned not only with the possible loss of strength of the biceps muscle, but also with the cosmetic appearance. Tenodesis was consequently indicated for these athletes. Surgical indication was afforded also by recent
411
Figure 3 The biceps tendon is prepared with biological fibrin glue (Tissucolâ, Baxter).
literature, which shows that patients with tendon rupture and displacement of the LHB muscle suffer from permanent disabilities, independently of any shoulder problems locally on the distal upper arm. If tenodesis is not performed, strength and endurance in the muscle are reported to be decreased by about 25%.6 On the other hand, biceps tenodesis allows the maintenance of the length-tension relationship of the biceps muscle, it allows maximum elbow function with maintenance of elbow flexion and supination, and it results in a better cosmetic appearance.14 Tenodesis techniques have traditionally involved bony fixation of the tendon to the proximal humerus through an open or arthroscopic technique. The tendon can be fixed proximally in the bicipital groove, or more distally under the pectoralis major tendon. Furthermore, multiple techniques of fixation can be used including bony tunnels, bone anchors, staples, or interference screws. Earlier techniques of transposition of the LHBT to the conjoint tendon have involved direct tenodesis to the coracoid process.7,17 To our knowledge, mini-open without arthroscopic assistance tenodesis of the LHBT to the bicipital groove has been described only by one author.3 This technique has been adopted for a series of 5 professional wrestlers with an acute rupture of the tendon while fighting. The overall results of biceps tenodesis reported in the literature are quite varied. Recently, Weber and Kauffman23 presented the results of 81 patients using a mini-open sub-pectoral tenodesis technique. At mean follow-up of 6.7 years, the authors concluded that this technique had acceptable long-term outcomes without the complexity associated with all-arthroscopic techniques. In a series of 22 patients undergoing an open subpectoral biceps tenodesis, Mazzocca et al15 demonstrated excellent results, preserving soft tissue and positioning the biceps tendon in an anatomic position beneath the pectoralis tendon. This technique involves both arthroscopic and open techniques. As a new alternative to traditional tenodesis techniques, Verma et al8,22 has described the subdeltoid arthroscopic
412
Figure 4
M. Tangari et al.
A-C, The surgical technique: long head of the biceps tendon mini-open tenodesis performed with a 5-mm suture anchor.
A limitation of this study is the small number of patients treated; but, the study group is represented by professional wrestlers, a very selected group. On the other hand, the average follow-up is considerably longer than that of other studies.
Conclusions The mini-open approach to tendon rupture and tenodesis without arthroscopic assistance is still a valid surgical procedure. We have performed a mini-open technique in 5 professional wrestlers. Furthermore, in this very selected group, functional and cosmetic results have been excellent, and it allowed athletes to return quickly to their sport activity.
Disclaimer The authors, their immediate families, and any research foundations with which they are affiliated have not received any finaneicial payments or other benefits from any commercial entity related to the subject of this article. No outside funding or grants were received that assisted this study. IRB approval was not required. Figure 5 Cosmetic appearance of the arm of the same wrestler at the follow-up.
transfer of the LHB to the conjoint tendon. Again, this technique combines both open and arthroscopic surgery, and it demonstrated no loss of strength and a 95% resolution of preoperative biceps symptoms in a continually followed series. In our small but selected series, we obtained excellent results both for function and cosmetics, no postoperative complications, and, at an average follow-up of over 7 years, all the athletes complained of no pain or loss of strength and athletic performances were fully exploited.
References 1. Boileau P, Krishnan SG, Coste JB, Walch G. Arthroscopic biceps tenodesis: A new technique using bioabsorbable screw fixation. Tech Shoulder Elbow Surg 2001;2:153-65. 2. Boileau P, Walch G. A new technique for tenodesis of the long head of the biceps using bioabsorbable screw fixation. J Shoulder Elbow Surg 1999;8:557. 3. Burkhead WZ. The biceps tendon. In: The shoulder, Ed. Rockwood and Matsen; 1990; Chapter 20. p. 830-1.
Biceps tendon tenodesis in professional wrestlers 4. Constant CR, Murley AHG. A clinical method of functional assessment of the shoulder. Clin Orthop 1987;214:160-4. 5. Cope MR, Ali A, Bayliss NC. Biceps rupture in bodybuilders: Three case reports of rupture of the long head of the biceps at the tendon labrum junction. J Shoulder Elbow Surg 2004;13:580-2. doi:10.1016/ j.jse.2004.03.003 6. Deutch SR, Gelineck J, Johannsen HV, Sneppen O. Permanent disabilities in the displaced muscle from rupture of the long head tendon of the biceps. Scand J Med Sci Sports 2005;15:159-62. doi: 10.1111/j.1600-0838.2004.00421 7. Dines D, Warren RF, Inglis AE. Surgical treatment of the long head of the biceps. Clin Orthop Rel Res 1982;164:165-71. 8. Drakos MC, Verma NN, Gulotta LV, Potucek F, Taylor S, Fealy S, et al. Arthroscopic transfer of the long head of the biceps tendon: functional outcome and clinical results. Arthroscopy 2008;24:217-23. doi:10.1016/j.arthro.2007.07.030 9. Ferry AT, Lee GH, Murphy R, Romeo AA, Verma NN. A longhead of biceps tendon rupture in a fast pitch softball player: A case report. J Shoulder Elbow Surg 2009;18:e14-7. doi:10.1016/j. jse.2008.04.006 10. Froimson AL, Oh L. Keyhole tenodesis of biceps origin at the shoulder. Clin Orthop 1975;112:245-9. 11. Garstman GM, Hammerman SM. Arthroscopic biceps tenodesis operative technique. Arthroscopy 2000;16:550-2. 12. Gilcreest EL. The common syndrome of rupture dislocation and elongation of the long head of the biceps brachii. Surg Gynecol Obstet 1934;58:322-39. 13. Klepps S, Hazrati Y, Flatow E. Arthroscopic biceps tenodesis. Arthroscopy 2002;18:1040-5.
413 14. Mazzocca AD, Noerdlinger MA, Romeo AA. Mini open and sub pectoral biceps tenodesis. Oper Tech Sports Med 2003;11:24-31. 15. Mazzocca AD, Rios CG, Romeo AA, Arciero RA. Subpectoral biceps tenodesis with interference screw fixation. Arthroscopy 2005;21:e1-5. doi:10.1016/j.arthro.2005.04.002 16. Morrey BF, An KN, Chao EYS. Functional evaluation of the elbow. In: Morrey BF, editor. The elbow and its disorders. Edition 2. Philadelphia, PA: WB Saunders; 1993. p. 86-9. 17. Post M, Benca P. Primary tendonitis of the long head of the biceps. Clin Ortho Rel Res 1989;246:117-25. 18. Pratt DA, Tennent TD. Proximal biceps rupture: management of an unusual injury in an arm wrestler. Br J Sports Med 2007;41:459. doi: 10.1136/bjsm.2006.031708 19. Refior HJ, Sowa D. Long head of the biceps brachii: sites of predilection for degenerative lesions. J Shoulder Elbow Surg 1995;4:436-40. 20. Sekiya JK, Elkousy HA, Rodosky MW. Arthroscopic biceps tenodesis using the percutaneous intra-articular transtendon technique. Arthroscopy 2003;19:1137-41. doi:10.1016/j.arthro.2005.04.002 21. Turek SL. Orthopaedics: Principles and their application. Edition 3. Philadelphia, PA: JB Lippincott; 1977. p. 834. 22. Verma NN, Drakos M, O’Brien SJ. Arthroscopic transfer of the long head of the biceps to the conjoint tendon. Arthroscopy 2005;21:1-5. doi:10.1016/j.arthro.2005.03.032 23. Weber SC, Kauffman J. Subpectoral biceps tenodesis in the management of tears of the long head of the biceps: Long term follow-up. Arthroscopy 2003;19(5, suppl. 1):21. doi:10.1016/S0749-8063(07)60092-9 24. Wiley WB, Meyers FJ, Weber SC, Pearson SE. Arthroscopic assisted mini-open biceps tenodesis: Surgical technique. Arthroscopy 2004;20: 444-6. doi:10.1016/j.arthro.2004.01.018
www.elsevier.com/locate/ymse
Long head of the biceps tendon rupture in professional wrestlers: treatment with a mini-open tenodesis Mario Tangari, MDa, Stefano Carbone, MDb,*, Mimmo Gallo, MDc, Andrea Campi, MDc a
Department of Hand Surgery, ‘‘S. Giovanni-Addolorata’’ Hospital, Via dell’Amba Aradam, Rome, Italy Department of Orthopaedic and Traumatology, University of Rome ‘‘Sapienza’’, P.le Aldo Moro, 5, Rome, Italy c Department of Orthopaedic and Traumatology, ‘‘S. Giovanni-Addolorata’’ Hospital, Via dell’Amba Aradam, Rome, Italy b
Background: The aim of this study is to assess the validity of a mini-open tenodesis of the long head of the biceps tendon (LHBT) performed on 5 professional wrestlers injured while fighting. Methods: Five professional wrestlers with an acute rupture of the LHBT were treated with a mini-open tenodesis procedure without arthroscopic assistance. This technique is performed with 2 miniscule incisions of the skin. The tendon is prepared with biological fibrin glue and with a No. 2 Fiberwire; after that, the tendon is sutured to the bicipital groove with a suture anchor. At the follow-up exam (average 7.6 years; range, 2-13), clinical assessments were obtained with the Constant score (CS) and Mayo Elbow Performance Score (MEPS). Forearm flexion strength was measured with a dynamometer, and a magnetic resonance image was also obtained. Results: At the follow-up, the average age of the patients was 32.6 years (range, 28-40). The average CS of the involved shoulder was 95 points (range, 92-98), compared to 97 points (range, 94-98) of the contralateral side (P ¼ .37). The MEPS was 99.76 for the elbow of the involved side and 99.84 for the contralateral one (P ¼ .34). No significant difference was noted for the forearm flexion strength (P ¼ .31). Discussion: In this study, patients were all high-demand wrestlers and biceps tenodesis was mandatory. Mini-opening without arthroscopic assistance tenodesis of the long head of the bicep tendon to the bicipital groove has been used for these professional wrestlers. Functional and cosmetic results of this technique have been excellent, and it allowed athletes to return shortly to their sport activity. Level of evidence: Level IV, Case Series, Treatment Study. Ó 2011 Journal of Shoulder and Elbow Surgery Board of Trustees. Keywords: Biceps tenodesis; mini-open tenodesis; long head of the biceps tendon rupture; wrestlers
Rupture of the long head of the biceps tendon (LHBT) is a common tendon injury, and, according to Gilcreest,12 it represents 90% of biceps ruptures. He also noted that an acute, traumatic rupture of this tendon occurs most often when a person is raising a weight of 68 kg or more. Otherwise, ruptures of the LHBT are commonly caused by *Reprint requests: Stefano Carbone, MD, University of Rome, ‘‘Sapienza’’, P.le Aldo Moro, 5, Rome, Italy. E-mail address: [email protected] (S. Carbone).
degenerative changes within the tendon and are associated with pathologies of the subacromial space. LHBT pathology ranges from simple cases of tendonitis to more complex pathologies such as tendon instability (subluxation or dislocation) and rupture (partial or complete). The common site of rupture occurs within the bicipital groove; this predominantly occurs in men in their 6th or 7th decade of life as a result of the weakening of the tendon by degenerative process.19 Less commonly, ruptures have been reported in weight lifters at the musculotendinous junction
1058-2746/$ - see front matter Ó 2011 Journal of Shoulder and Elbow Surgery Board of Trustees. doi:10.1016/j.jse.2010.08.008
410 and within the muscle belly.5 Recently, the diagnosis and treatment of a 36-year-old man who sustained a proximal biceps rupture while arm wrestling and his operative management have been described;18 in addition, there is a report of an isolated LHBT rupture in an underhand thrower, as a result of the increased bicep muscle activity or increased tendon excursion in the windmill-pitching motion.9 While nonoperative treatment is often successful, operative treatment may be required for those patients who do not achieve acceptable pain control or functional recovery. Furthermore, surgical repair is recommended for acute ruptures in those patients with high demands and in whom slight loss of flexion and supination strength is not well tolerated. Biceps tenodesis is the most commonly performed procedure for biceps tendon rupture.10,11 Numerous surgical techniques of tenodesis have been advocated; however, many of these require moving the biceps tendon to the coracoid process with undue medial dissection followed by prolonged restriction of shoulder and elbow movement with substantial morbidity.11,13 Keyhole tenodesis was introduced to overcome these inadequacies, with the tendon attached to the bone which permits immediate mobilization.5 Fixation of the tendon to the bone with interference screw has been used by some authors, combining this technique to the arthroscopic surgery.1,2 Other authors have combined the arthroscopic with percutaneous, intra-articular trans-tendon technique or with miniopen tenodesis.20,24 The mini-open approach to the tendon rupture and tenodesis without arthroscopic assistance has been described by Burkhead in 1990.3 We have adopted this mini-open technique for 5 professional wrestlers, using 1 suture anchor applied to the bicipital groove with 2 miniincisions of the skin (2 cm), 1 to get to the tendon stump, and the other to suture the tendon to the bone.
Materials and method Between 1997 and 2008, 5 professional wrestlers were referred to our hospital after they experienced a snap and shoulder pain while fighting in the gym. They were seen by 1 of the authors after a average time of 3 days (range, 1-10). Preoperative diagnosis was made by clinical examination, based on the presence of the classic Popeye sign or a less striking descent of the biceps muscle in the middle part of the arm; a magnetic resonance image was obtained in all cases to confirm the diagnosis and to exclude other lesions of the gleno-humeral joint. They all denied having used anabolic steroids. The surgical procedure is performed in the beach-chair position. The arm is positioned adducted to the body, in neutral rotation and with about 20 of extension for a better visualization of the humeral head and bicipital groove. All biceps tendon tears in this study were extra-articular and did extend to the bicipital groove. With the ultrasound probe (7,5 GHz), the exact localization of the tendon stump is obtained and then marked with a surgical pen. Maintaining the arm in the same position, with ultra-sound control, the bicipital groove is located and marked. In correspondence of the 2 marked areas,
M. Tangari et al.
Figure 1
The mini-incision of the skin to get to the tendon stump.
a 2-cm skin incision is made (Figure 1). The tendon stump is felt under the finger, the brachialis fascia covering the biceps is then opened, and the biceps tendon is retrieved out of the wound (Figure 2). To ensure appropriate tensioning of the biceps tendon, the proximal portion of the tendon is resected to leave 20-25 mm of tendon proximal to the musculotendinous portion of the biceps.15 Using a Krackow or whip-stich, a No. 2 Fiberwire (Arthrex, Naples, FL) nonabsorbable suture is weaved into the proximal 15 mm of tendon. To obtain faster healing of the tendon to the bone, in all but 1 patient, the LHBT is prepared with biological fibrin glue (Tissucolâ, Baxter) (Figure 3). A suture passer is inserted in the superior skin incision and it is guided under the brachialis fascia until the second incision. Subsequently, the tendon stump is tied to the suture passer and the last is pulled upward to the superior incision. The bone in the area of the upper portion of the bicipital groove is prepared using a burr until bleeding. Then, a 5-mm suture anchor (Arthrex) is inserted in the upper reachable (from the skin incision) portion of the bicipital groove. The sutures from the tendon stump are then tied to those of the anchor and the knots tightened with an arthroscopic suture passer (surgical technique illustrated in Figures 4, A-C). After surgery, a sling is applied for 7 days and then self-assisted recovery of range of motion is allowed. Flexion of the elbow and supination of the hand against resistance is forbidden for 2 months; finally, all the professional athletes returned to their full activities. At follow-up (average time, 7.6 years; range, 2-13), objective evaluation of the shoulder and the elbow was obtained with the Constant score (CS)4 and the Mayo Elbow Performance Score (MEPS).16 Flexion strength of the forearm (with the forearm flexed at 90 and the arm adducted to the body, with the hand in full supination) (1 point ¼ 1 lb) was measured with the use of the MicroFET dynamometer (Hoggan Health Industries, West Jordan, UT). Finally, an MRI was also obtained. The differences of the CS, MEPS, and the flexion strength of the forearm between the involved and contralateral sides were analyzed with the Chi-square test. P < .05 was considered to be significant.
Results The average age at the time of injury was 25.4 years (range, 2327) and the right shoulder was involved in 5 cases. At the followup, the mean age of the patients was 32.6 years (range, 28-40).
Biceps tendon tenodesis in professional wrestlers
Figure 2
The biceps tendon is retrieved out of the wound.
After the operation, we did not observe any complications. At follow-up, the mean CS of the involved shoulder was 95 points (range, 92-98), compared to 97 points (range, 94-98) on the contralateral side (P ¼ 0.37). The range of motion was similar in the 2 shoulders. Mean flexion strength of the forearm result was 42 points (range, 38-50) on the affected side (dominant side) and 40 on the contralateral one (range, 38-46) (P ¼ .31). The MEPS was 99.76 for the elbow of the involved side and 99.84 for the contralateral one (P ¼ .34). On MRI scans of all patients, the long head of the biceps appeared thickened and healed to the bicipital groove; in 2 of the 5 athletes (40%), a Bankart lesion was noted with a concomitant Hill-Sachs of the humeral head. Despite these MRI findings, all the shoulders were clinically stable. Cosmesis of the arm was judged as excellent in all cases, both by the patients and the surgeon (Figure 5). At an average of 5 months (range, 3-7) after surgery, all the wrestlers had returned to their professional sport activity, and 4 of the 5 are still professional wrestlers.
Discussion There is controversy in the literature regarding treatment of ruptures of the long head of the biceps (LHB). Most agree that surgical correction is usually not necessary and nonsurgical therapy has been advocated by many. For example, Turek21 stated that ‘‘the operation is contraindicated except in the young individual for vigorous occupations or sports or for cosmesis. It should never be performed in the elderly or persons with light activities.’’ In this study, the patients were all high-demanding wrestlers; all were aged around 25 years, considerably younger than the usual age of presentation of ruptures of the LHB. All of them were highly concerned not only with the possible loss of strength of the biceps muscle, but also with the cosmetic appearance. Tenodesis was consequently indicated for these athletes. Surgical indication was afforded also by recent
411
Figure 3 The biceps tendon is prepared with biological fibrin glue (Tissucolâ, Baxter).
literature, which shows that patients with tendon rupture and displacement of the LHB muscle suffer from permanent disabilities, independently of any shoulder problems locally on the distal upper arm. If tenodesis is not performed, strength and endurance in the muscle are reported to be decreased by about 25%.6 On the other hand, biceps tenodesis allows the maintenance of the length-tension relationship of the biceps muscle, it allows maximum elbow function with maintenance of elbow flexion and supination, and it results in a better cosmetic appearance.14 Tenodesis techniques have traditionally involved bony fixation of the tendon to the proximal humerus through an open or arthroscopic technique. The tendon can be fixed proximally in the bicipital groove, or more distally under the pectoralis major tendon. Furthermore, multiple techniques of fixation can be used including bony tunnels, bone anchors, staples, or interference screws. Earlier techniques of transposition of the LHBT to the conjoint tendon have involved direct tenodesis to the coracoid process.7,17 To our knowledge, mini-open without arthroscopic assistance tenodesis of the LHBT to the bicipital groove has been described only by one author.3 This technique has been adopted for a series of 5 professional wrestlers with an acute rupture of the tendon while fighting. The overall results of biceps tenodesis reported in the literature are quite varied. Recently, Weber and Kauffman23 presented the results of 81 patients using a mini-open sub-pectoral tenodesis technique. At mean follow-up of 6.7 years, the authors concluded that this technique had acceptable long-term outcomes without the complexity associated with all-arthroscopic techniques. In a series of 22 patients undergoing an open subpectoral biceps tenodesis, Mazzocca et al15 demonstrated excellent results, preserving soft tissue and positioning the biceps tendon in an anatomic position beneath the pectoralis tendon. This technique involves both arthroscopic and open techniques. As a new alternative to traditional tenodesis techniques, Verma et al8,22 has described the subdeltoid arthroscopic
412
Figure 4
M. Tangari et al.
A-C, The surgical technique: long head of the biceps tendon mini-open tenodesis performed with a 5-mm suture anchor.
A limitation of this study is the small number of patients treated; but, the study group is represented by professional wrestlers, a very selected group. On the other hand, the average follow-up is considerably longer than that of other studies.
Conclusions The mini-open approach to tendon rupture and tenodesis without arthroscopic assistance is still a valid surgical procedure. We have performed a mini-open technique in 5 professional wrestlers. Furthermore, in this very selected group, functional and cosmetic results have been excellent, and it allowed athletes to return quickly to their sport activity.
Disclaimer The authors, their immediate families, and any research foundations with which they are affiliated have not received any finaneicial payments or other benefits from any commercial entity related to the subject of this article. No outside funding or grants were received that assisted this study. IRB approval was not required. Figure 5 Cosmetic appearance of the arm of the same wrestler at the follow-up.
transfer of the LHB to the conjoint tendon. Again, this technique combines both open and arthroscopic surgery, and it demonstrated no loss of strength and a 95% resolution of preoperative biceps symptoms in a continually followed series. In our small but selected series, we obtained excellent results both for function and cosmetics, no postoperative complications, and, at an average follow-up of over 7 years, all the athletes complained of no pain or loss of strength and athletic performances were fully exploited.
References 1. Boileau P, Krishnan SG, Coste JB, Walch G. Arthroscopic biceps tenodesis: A new technique using bioabsorbable screw fixation. Tech Shoulder Elbow Surg 2001;2:153-65. 2. Boileau P, Walch G. A new technique for tenodesis of the long head of the biceps using bioabsorbable screw fixation. J Shoulder Elbow Surg 1999;8:557. 3. Burkhead WZ. The biceps tendon. In: The shoulder, Ed. Rockwood and Matsen; 1990; Chapter 20. p. 830-1.
Biceps tendon tenodesis in professional wrestlers 4. Constant CR, Murley AHG. A clinical method of functional assessment of the shoulder. Clin Orthop 1987;214:160-4. 5. Cope MR, Ali A, Bayliss NC. Biceps rupture in bodybuilders: Three case reports of rupture of the long head of the biceps at the tendon labrum junction. J Shoulder Elbow Surg 2004;13:580-2. doi:10.1016/ j.jse.2004.03.003 6. Deutch SR, Gelineck J, Johannsen HV, Sneppen O. Permanent disabilities in the displaced muscle from rupture of the long head tendon of the biceps. Scand J Med Sci Sports 2005;15:159-62. doi: 10.1111/j.1600-0838.2004.00421 7. Dines D, Warren RF, Inglis AE. Surgical treatment of the long head of the biceps. Clin Orthop Rel Res 1982;164:165-71. 8. Drakos MC, Verma NN, Gulotta LV, Potucek F, Taylor S, Fealy S, et al. Arthroscopic transfer of the long head of the biceps tendon: functional outcome and clinical results. Arthroscopy 2008;24:217-23. doi:10.1016/j.arthro.2007.07.030 9. Ferry AT, Lee GH, Murphy R, Romeo AA, Verma NN. A longhead of biceps tendon rupture in a fast pitch softball player: A case report. J Shoulder Elbow Surg 2009;18:e14-7. doi:10.1016/j. jse.2008.04.006 10. Froimson AL, Oh L. Keyhole tenodesis of biceps origin at the shoulder. Clin Orthop 1975;112:245-9. 11. Garstman GM, Hammerman SM. Arthroscopic biceps tenodesis operative technique. Arthroscopy 2000;16:550-2. 12. Gilcreest EL. The common syndrome of rupture dislocation and elongation of the long head of the biceps brachii. Surg Gynecol Obstet 1934;58:322-39. 13. Klepps S, Hazrati Y, Flatow E. Arthroscopic biceps tenodesis. Arthroscopy 2002;18:1040-5.
413 14. Mazzocca AD, Noerdlinger MA, Romeo AA. Mini open and sub pectoral biceps tenodesis. Oper Tech Sports Med 2003;11:24-31. 15. Mazzocca AD, Rios CG, Romeo AA, Arciero RA. Subpectoral biceps tenodesis with interference screw fixation. Arthroscopy 2005;21:e1-5. doi:10.1016/j.arthro.2005.04.002 16. Morrey BF, An KN, Chao EYS. Functional evaluation of the elbow. In: Morrey BF, editor. The elbow and its disorders. Edition 2. Philadelphia, PA: WB Saunders; 1993. p. 86-9. 17. Post M, Benca P. Primary tendonitis of the long head of the biceps. Clin Ortho Rel Res 1989;246:117-25. 18. Pratt DA, Tennent TD. Proximal biceps rupture: management of an unusual injury in an arm wrestler. Br J Sports Med 2007;41:459. doi: 10.1136/bjsm.2006.031708 19. Refior HJ, Sowa D. Long head of the biceps brachii: sites of predilection for degenerative lesions. J Shoulder Elbow Surg 1995;4:436-40. 20. Sekiya JK, Elkousy HA, Rodosky MW. Arthroscopic biceps tenodesis using the percutaneous intra-articular transtendon technique. Arthroscopy 2003;19:1137-41. doi:10.1016/j.arthro.2005.04.002 21. Turek SL. Orthopaedics: Principles and their application. Edition 3. Philadelphia, PA: JB Lippincott; 1977. p. 834. 22. Verma NN, Drakos M, O’Brien SJ. Arthroscopic transfer of the long head of the biceps to the conjoint tendon. Arthroscopy 2005;21:1-5. doi:10.1016/j.arthro.2005.03.032 23. Weber SC, Kauffman J. Subpectoral biceps tenodesis in the management of tears of the long head of the biceps: Long term follow-up. Arthroscopy 2003;19(5, suppl. 1):21. doi:10.1016/S0749-8063(07)60092-9 24. Wiley WB, Meyers FJ, Weber SC, Pearson SE. Arthroscopic assisted mini-open biceps tenodesis: Surgical technique. Arthroscopy 2004;20: 444-6. doi:10.1016/j.arthro.2004.01.018