SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA
w w w . r b o . o r g . b r
Update
Article
Disorders
of
the
long
head
of
the
biceps:
tenotomy
versus
tenodesis
夽
Fabiano
Rebouc¸as
Ribeiro
∗,
André
Petry
Sandoval
Ursolino,
Vinicius
Ferreira
Lima
Ramos,
Fernando
Hovaguim
Takesian,
Antonio
Carlos
Tenor
Júnior,
Miguel
Pereira
da
Costa
HospitaldoServidorPúblicoEstadualdeSãoPaulo,DepartamentodeOrtopedia,SãoPaulo,SP,Brazil
a
r
t
i
c
l
e
i
n
f
o
Articlehistory: Received18April2016 Accepted31May2016 Availableonline28April2017
Keywords:
Shoulderimpingementsyndrome Tenotomy
Tenodesis Rotatorcuff Shoulderpain
a
b
s
t
r
a
c
t
Disordersofthelongheadofbicepstendonarecommoninclinicalpractice.Theircauses couldbedegenerative,inflammatory,instability(subluxationorluxation)ortraumatic.They aregenerallyassociatedtootherdiseasesoftheshoulder,mainlyrotatorcuffinjuries. Cur-rently,thereiscontroversyintheliteratureregardingtheindicationsforsurgicaltreatment andthechoiceofthebesttechniqueforeachcase,duetothepossibilityofestheticdeformity, lossofmusclestrength,andresidualpain.
Theobjectiveofthisstudywastoidentifytheindicationsforsurgicaltreatment,thebest surgicaltechnique,andtheadvantagesanddisadvantagesofeachtechniquedescribedin theorthopedicliteratureforthetreatmentoflongheadofbicepstendoninjuries.
Arevisionoftheorthopedicmedicalliteratureonthefollowingdatabases:Biblioteca Regional deMedicina(BIREME),Medline,PubMed,CochraneLibraryandGoogleScholar, comprisingarticlespublishedintheperiodfrom1991to2015.
©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http:// creativecommons.org/licenses/by-nc-nd/4.0/).
Lesões
do
cabo
longo
do
bíceps:
tenotomia
versus
tenodese
Palavras-chave:
Síndromedecolisãodoombro Tenotomia
Tenodese Bainharotadora Dordeombro
r
e
s
u
m
o
Aslesõesdacabec¸alongadotendãobicipital(CLB)sãocomunsnapráticaclínicaepodem tercausasdegenerativas,inflamatórias,instabilidades(subluxac¸ãoouluxac¸ão)ou traumáti-cas.Geralmente,elasestãoassociadasaoutrasdoenc¸asdoombro,principalmentealesões domanguitorotador.Atualmente,existemcontrovérsiasquantoàsindicac¸õesdos trata-mentoscirúrgicoseàescolhadamelhortécnicaparacadacaso,devidoàpossibilidadede deformidadeestética,perdadaforc¸amuscularedorresidual.
夽
StudyconductedattheHospitaldoServidorPúblicoEstadualdeSãoPaulo,GrupodeOmbroeCotovelo,SãoPaulo,SP,Brazil. ∗ Correpondingauthor.
E-mail:fabianoreboucas@globo.com(F.R.Ribeiro).
http://dx.doi.org/10.1016/j.rboe.2017.04.001
Oobjetivodesteestudofoiidentificarasindicac¸õesdotratamentocirúrgico,amelhor téc-nicacirúrgicaeasvantagensedesvantagensdecadatécnicadescritasnaliteraturamédica ortopédicanotratamentodaslesõesdaCLB.
Foirealizadarevisãodaliteraturamédicaortopédicadisponívelnabasededadosda Bib-liotecaRegionaldeMedicina(BIREME),Medline,PubMed,CochraneLibraryeGoogleScholar, incluindoartigospublicadosnoperíodode1991a2015.
©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http:// creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
Thelongheadofthebicipitaltendon(LHB)isintra-articular and extrasynovial; it has a flat surface at its origin and becomesroundedinthebicipitalgroove.Itoriginatesinthe superiorlabrum andthe supraglenoidtubercle.1 Vangsness
etal.,2 inacadavericstudy,classifiedtheoriginoftheLHB
intofourtypes;type3,withinputfromtheanteriorand pos-terior labrum,wasthe mostcommon.Lucianoet al.,3 in a
histologicalstudy,concludedthatmacroscopicinspectionis notsufficient to assess the origin ofthe tendon and that, whenanalyzedmicroscopically,thecontributionofthe ante-rior labrum isgreater than that suggestedby macroscopic inspection.
Theintra-articularportionoftheLHBhasanoblique incli-nationofapproximately30–40◦;itpassesthroughtheanterior
rotator interval shoulder and leaves the joint through the intertuberculargroove,whichhasameanof4mmdepthand 56◦ofmedialtilt.
TheLHB’sintra-articularstabilizersarethebiceps reflec-tionpulley(themostimportantstabilizer,composedofthe upperglenohumeralandcoracohumeralligaments)andthe fibersofthe subscapularand supraspinalmusclestendons. Thestabilizersoftheextra-articularportionarethe intertu-berculargrooveandthetransverseligament(lessimportant stabilizer, composed of fibers of the subscapularis muscle tendon).4
The LHB is innervated by the musculocutaneous nerve (C5–C7roots),anditisvascularizedbytheascendingbranch oftheanteriorcircumflexartery,labialbranchesofthe supras-capularartery,andbranchesofthethoracoacromialartery.It hastwoanatomicalzonesrelatedtoitsvascularization:the tractionzone, withnormalvascularization, andthe sliding zone,inwhichthereisareductioninvascularsupply,situated from1.2to3cmfromitsoriginandthatmaybeassociated withdegenerativelesions.5
ThefunctionoftheLHBintheshoulderiscontroversial intheliterature;someauthors consider ittobea vestigial structure with no function (embryonic remnant),6–8 while
othersattribute importantfunctionstoit,suchashumeral headdepressantandanteriorstabilization.9–13Intheinjured
shoulder(unstableorwithrotatorcuffinjury),itis consensu-allyunderstoodtohaveastabilizingfunction,butcausespain. Levyetal.,8inanelectromyographicstudy,demonstratedthat
whenelbowfunctionwasisolated,theLHBhadnofunction during movement ofthe shoulder arc; these authors then concluded that the function of the LHB in the shoulder
would be interconnected with the movements of the elbow.
LHB lesionsarecommoninclinicalpracticeandmaybe duetodegenerative,inflammatory,instability-related (sublux-ationordislocation),andtraumaticcauses.Theinflammatory causesaredividedasfollows:primarycauses,whicharerarer, representingonly5%ofthecasesandusuallyaffectingyoung patientsandthrowingathletes;secondarycauses,whichare more commonand usually associatedwithother shoulder disorders,suchasrotatorcufftears,impingementsyndrome, and superior labrum anterior to posterior(SLAP) lesion,in whichthetendonundergoesmicroscopicand/ormacroscopic alterations.14
In mostcases, the physicalexamination isnon-specific and makes the initial diagnosis difficult. Upon inspection, the Popeye sign, limitation of passive elevation (hourglass biceps, described by Boileau et al.15) and pain on
palpa-tion inintertubercularsulcus maybeobserved.Stimulative tests forimpingement syndrome are generally positivefor LHB disorders.Tests that are morespecificforSLAP lesion canalsobepositive,suchastheO’Brien test,16 bicepsload
test,17 crank test,18 and speed test.18 TheYergassontest19
is positive inthe case ofLHB instability inintertubercular groove.
AsanauxiliarymethodtoclinicallydiagnoseLHBinjuries, the anesthetic test can be made, injecting 8–10mL of local anesthetic into the subacromial space, which causes pain relief in casesofimpingement syndromeand rotator cuff injuries, but not in LHB disorders. It is also possi-ble to inject the intertubercular groove (preferably with the aid of ultrasonography), in which case pain would improve.14
ComplementarytestscommonlyusedtoassessLHB dis-ordersareradiographoftheshoulderbytangentialincidence (Fisk20 method),whichevaluatesthepresenceofstructural
Habermeyeretal.24classifiedthepathologiesoftheLHB
intofourtypes,accordingtotheintegrityofbicepsreflection pulley:type1,isolatedlesionsofthesuperiorglenohumeral ligament(SGHL);type2,SGHLlesionandpartialsupraspinal tendonlesion;type3,SGHLandsubscapularistendonlesions; andtype4,lesionofallthesestructures.Walchetal.25
clas-sifiedLHBdisordersaccordingtotheanatomicallocationof the lesion.Lafosseet al.26 classified LHB lesions according
toarthroscopic findingswhen evaluatingthe directionand extentofinstability,themacroscopicappearanceofthe ten-donandthepresenceofassociatedrotatorcuffinjuries.
Conservativetreatmentisusuallytheinitialchoicefor iso-latedlesionsandforacuteLHBruptures;itconsistsofrest, analgesics,non-steroidalanti-inflammatorydrugs, corticos-teroidinjection,physiotherapy, and change indailyhabits. Whentreatment fails,or whenthereisanother associated lesion in the shoulder (rotator cuff injury, labial lesion,or instability),surgicaltreatmentisindicated,whichmayinclude debridementofthelesion,acromioplasty,simpletenotomy,or tenotomyassociatedwithLHBtenodesis.
Currently,therearecontroversiesregardingtheindications ofsurgicaltreatmentsandthedecisionofthebesttechnique foreachcase,duetothepossibilityofestheticdeformity,loss ofmusclestrength,andresidualpain.
Thisstudy aimedtoidentifytheindicationsforsurgical treatment,the bestsurgicaltechnique, andthe advantages anddisadvantagesofeachtechnique,describedinthe ortho-pedicmedicalliterature,inthetreatmentofLHBlesions.
Material
and
methods
The orthopedic medical literature was reviewed in the database of the Biblioteca Regional de Medicina (BIREME), Medline, PubMed, Cochrane Library, and Google Scholar, includingpublicationsfrom1991to2015,fromthefollowing searchcombinations:bicipitaltendonlong head,tenotomy, andtenodesis.
Articles focused on injuries of long head of the biceps brachii muscle, written in English and Portuguese, were selectedforthepresentreview.
Results
Accordingto Khazamet al.,4 themainsurgical indications
forLHBlesions,otherthanfailureofconservativetreatment, are partiallesions affecting over 25% of the tendon diam-eter,longitudinal injuries, instabilities with subluxationor medial dislocation, association with subscapularis muscle tendoninjury,hourglassbiceps(describedbyBoileauetal.27)
anddetachmentoftheglenoidlabrum(SLAPlesions).They describedthat LHBshould notberoutinelytenotomized in thetreatmentofrotatorcufflesions.
Hsuetal.,28inasystematicreviewwithcasesbetween1966
and2010,showeda41%incidenceofPopeyedeformityincases ofLHBtenotomy,vs.25%intenodesis.Theyalsoobservedthat LHBtenodesisledtoresidualpainin24%ofcases,vs.17%in tenotomy.Theyconcludedthattherewasnoconsensusinthe literatureaboutthebestsurgicaltechnique,sincethestudies didnotpresentstatisticallysignificantdifferences.
Frostetal.,29inasystematicreviewincludingstudies
pub-lished between1982and 2008, concludedthat the success ratesforLHB tenotomyandtenotomyassociatedwith ten-odesis were similar. The Popeye type deformity was more frequently observed in the group that underwent isolated tenotomy,and wasgenerallynotperceived bythe patients. These authors concluded that tenotomy presented good results,regardlessofpatient’sage,andthattenodesisshould beconsideredinverythinpatientswhoareconcernedwith the possible esthetic deformity. They suggested that, due tothe disparity ofmethodologies and therelevance ofthe availablestudies,newrandomizedandcomparativestudies featuringbothtechniquesshouldbeconducted.
Boileau etal.,27 minaretrospectivestudy of68 patients
withirreparablerotatorcuffinjuries,treatedwithtenotomy ortenodesisoftheLHB,concludedthattheresultsofthetwo techniquesweresimilar.TheyalsoobservedthatthePopeye deformitywaspresentin62%ofcases,butitwasnotalways perceivedbythepatient.
Osbahr et al.,30 in aretrospective study of160 patients
whounderwentLHBtenotomyand/ortenodesis,foundno sig-nificantdifferencesregardingcosmeticdeformity,pain, and musclespasm.
Galassoetal.,31inarandomizedclinicaltrial,observedthat
patientswhounderwentLHBtenotomyhadalossofforearm supinationstrengthwhencomparedwiththosewho under-wenttenodesis.InthestudybyShanketal.,32thisdifference
wasnotstatisticallysignificant.
Mariani et al.,33 in a retrospective study, compared the
resultsofsurgicalandconservativetreatmentinpatientswith acuteruptureoftheLHB.Theyconcludedthattherewasno significant differenceinpain results.Mostpatientsinboth groupsevolvedwithimprovement.Thenon-operatedgroup hadahigherincidenceofestheticdeformity.Nosignificant difference was observed in the shoulder and elbow range of motionbetween both groups. They alsoconcluded that patientsinthenon-operatedgroupreturnedearliertowork, but presented8% loss offlexion strength and 21% lossof supinationforceintheelbow.
Almeidaetal.,34inaprospectivecohortstudy,evaluated
the degreeofelbowflexionstrengthafterarthroscopicLHB tenotomyandobservedasignificantdeficitwhencompared withthecontralateralupperlimbandwiththecontrolgroup. In another prospectivecohort study, Almeida et al.35
eval-uated thepresenceofestheticdeformity afterarthroscopic LHBtenotomyandconcludedthatthePopeyedeformitywas presentin35.1%ofthesample.Malepatients,thosewithBMI below30,andthosewhowereoperatedonthedominantlimb hadmoreestheticcomplaints.
Inanon-randomizedretrospectivestudy,Ikemotoetal.36
betweenthegroupsregardingpaininthebicipitalgroove, Pop-eyesign,andtheESI.Statisticalsignificancewasobservedonly forthe UCLAscore,which presentedimprovementinboth groups,butmoresignificantlyinpatientssubmittedto teno-tomyassociatedwithLHBtenodesis.
Walchet al.37 performed isolated LHB tenotomy in 307
shoulderswithirreparablerotator cufflesionswithclinical andradiographicfollow-upforameanperiodof57months. Theyconcludedthat,incasesofirreparablelesions,aswell as inpatients who do not intendto performan adequate rehabilitation,LHBtenotomypresentsfavorableresults,with improvement of pain and function. Popeye deformity was observedinapproximately50%ofpatients.Thoseauthorsalso observedthatpatientsunder55yearsofagearemorelikely tocomplain ofestheticdeformity. Inthe same study, they alsoassessedtheacromiohumeraldistanceonshoulder radio-graphs,andobservedthattherewasnosignificantdecreaseof thisspace. Thissuggeststhat LHBtenotomydidnot accel-erate the natural course of the disorder for rotator cuff arthropathy.
Checchia et al.38 evaluated the results of arthroscopic
tenotomyoftheLHB in12 patientswithsymptomaticand irreparablerotatorcuffinjuriesandobservedpain improve-mentin100%ofcases.OnecasepresentedPopeyedeformity, andthemeanUCLAscorewas28.2points.Theyconcluded that LHB tenotomy may be indicated for pain relief in casesofirreparablerotatorcufflesions,especiallyinelderly patients.
Khazzametal.4andHsuetal.,28inreviewarticlesthat
com-paredLHBtenotomyandtenodesis,suggestedthatpatients over 40 years,sedentary, obese,who would not seek labor compensation,andwhodidnotmindtheestheticdeformity, wouldbetterindicatedforLHBtenotomy;conversely,patients under 40 years of age, with activities of greater demand, eutrophic,whowouldbebotheredbytheestheticdeformity orwhowouldseeklaborcompensation,wouldbebetter can-didatesforLHBtenodesis.
Godinhoet al.,39 inaretrospective study of63 patients,
developedasurgicaltechniqueknownasbicipital“jellyroll” tenodesis,inwhichLHBtenodesiswasindicatedafter teno-tomy when there was injury in up to 50% of the tendon, whetherornotassociatedwithrotatorcuffinjury,orwhen subluxationordislocationoccurred.Inthatsample,92.06%of thepatientswere satisfied,withoutlossofsupinationforce oftheforearmandelbowflexion.ThePopeyedeformitywas observedin11.1%ofthepatients.Theyobservedadifference intheassessmentoftheestheticdeformitybytheexaminer andbythepatient,andthatitsonsethadnocorrelationwith theagegroupandthesportpracticed.
Narvanietal.,40inaprospectivestudy,assessedtheresults
ofarthroscopicLHBanchorshapetenotomy,inwhichtwo inci-sionsweremadeinthetendon,onemoredistalandoblique, andthe otheratthetendonorigin,inwhichthe tenotomy was performed. They didnot observe the presence ofthe Popeyedeformityinthe12evaluatedpatientsandsuggested that,withtheflapmadeintheobliqueincision,thetendon wouldbetrappedintheintertuberculargroove,preventingthe estheticdeformity.
Checchiaetal.41describedatenodesistechniqueinwhich
theLHBtendonwasattachedwiththesutureofrotatorcuff
andassessedtheresultsof15patients.Theyobserved93.4% satisfactoryresultsintheUCLAscore,withimprovementof the range ofmotion;6.6%ofpatientspresentedthe Popeye deformity.Allpatientsweresatisfiedwiththesurgery.
Checchiaetal.42evaluatedtheresultsofarthroscopicLHB
tenodesiswithuseofbioabsorbableinterferencescrewsin16 patients.Thetenotomywasmadeattheoriginoftheglenoid labrum;thetenodesis,intheintertuberculargroove.TheUCLA scorewasusedtoevaluatetheresults,withamean of34.5 points.NoneofthepatientspresentedaPopeyedeformityand all patients weresatisfied withthe surgicaloutcome.They concludedthattheadvantagesoftenotomyassociatedwith tenodesis includethe prevention ofmuscular atrophy and maintenanceoftendonlength,muscletension,and flexion andsupinationforces,aswellasalowerriskofesthetic defor-mity.
Lutton et al.43 described an arthroscopic LHB tenodesis
techniqueusingbioabsorbablescrewfixationbelowthe inter-tubercular groove (suprapectoral region). According to the authors,somestudiessuggestthatLHB tenodesisproximal to the groove leads to a higher incidence of postopera-tive pain when compared with distal tenodesis, due to the possible maintenance of residual tenosynovitis. They retrospectivelycomparedpatientswhounderwentLHB teno-tomy and observed better pain results in the group in which tenodesis was made distal to the intertubercular groove.
Davidetal.44observedthatthechallengeofLHBtenodesis
inachievingacorrectlengthandtensionofthetendon.They observedthatthedecrease intendon/muscle tensioncould lead to muscle fatigue, estheticdeformity, and “crackling” during movement; however, in casesof excessive tension, therewouldbeahigherchanceofsynthesismaterialpullout andprocedurefailure.Inthesurgicaltechniqueused, arthro-scopic LHB tenodesis was performed in the suprapectoral region,usinginterferencescrewsandtwobonetunnels.They concluded thatthe arthroscopic techniquewas superiorto opensurgery;theinterferencescrewhadalowerfailureindex, thesuprapectoraltenodesiswasbetterthanthesubpectoral, and the use of two bone tunnels allowed better muscle tension.
Jarrettetal.45performedanatomicalstudiesoncadaversto
evaluatethebestplaceforLHBtenodesis.Thestudyusedas anatomicalparameterthemyotendinousjunctionoftheLHB, whichislocated2cmfromthesuperioredgeofthetendonof thepectoralismajormuscle,5.3cmfromthelessertubercle, 3.4cmlateraltothemusculocutaneousnerve,and4.6cmfrom the anterior humeralcircumflex artery (buffer zone). They concludedthattenodesisshouldbeperformedneartheupper borderofthetendonofthepectoralismajormuscleandtwo distaldigitalpulpsfromthelessertubercle.
Papp et al.,46 in a biomechanical study in cadavers,
suggestedthatmoreclinicalstudiescomparingmethodswere stillneeded.
Patzeretal.,47inabiomechanicalstudyincadavers,
com-paredfour tenodesistechniqueswithanchorsand interfer-ence screwsin the supra-and subpectoral positions. They concludedthatthetechniquewithinterferencescrews pre-sentedsuperiorresistancewhencomparedwiththe techni-que with anchors, in both the supra- and subpectoral positions.
Abrahametal.,48inasystematicreviewofcasesfrom2008
to2015,evaluatedtheresultsofthemedicalliteratureand comparedarthroscopicandopenLHBtenodesis.Onlystudies ofisolatedLHBlesionsorassociationwithSLAPlesionwere included.StudiesinwhichpatientspresentedLHBdisorders associatedwithotherpathologies,biomechanicalstudies,and animal studies were excluded. They concluded that both groupshadsatisfactoryresults,withnostatisticallysignificant difference.
Werneretal.,49inabiomechanicalstudyincadavers,
com-paredthestrengthandlengthandtensionrestorationofthe LHBintwotenodesistechniquesutilizinginterferencescrews: arthroscopicsuprapectoralandopensubpectoral.They con-cludedthatinarthroscopictenodesistherewasatendency toincreasethephysiologicaltensionofthetendon;this tech-niquewaslessresistanttocyclicalforceswhencomparedwith theopentechnique.
Valentiet al.50 described anarthroscopic LHB tenodesis
techniqueinwhichthetendonwasfixatedwithinterference screwsintheproximalintertuberculargroove.The tenode-siswasmade5mmdistaltotheoriginallocation,inorderto reducemyotendinoustensionandthusachievealower inci-denceofresidualpainwithoutcausingPopeyedeformity.
Bradyet al.,51 inamulticenterprospectivestudy,
evalu-atedtheresultsofarthroscopicLHBtenodesisperformedin theproximalintertuberculargroovewithinterferencescrews. Theyconcludedthatthetechniqueresultedina4.1%rateof revision,0.4%relatedtotheLHB,lowresidualpainindexes, andimprovedfunctionalscoresontheoperatedshoulder.
Gilmeretal.,52inaprospectivestudy,assessedtheefficacy
of arthroscopic and macroscopic evaluation of LHB disor-dersin62 patientsundergoingopensubpectoral tenodesis. Theysuggestedthatarthroscopicvisualizationcould under-estimateLHBlesions.Theyconcludedthatitwaspossibleto visualizeonly32%ofthetotallengthofthetendon.
Velliosetal.53conductedapopulationstudyintheUnited
StatesthroughadatabasetoassessthecurrenttrendforLHB tenodesisindication.TheyconcludedthatLHBopentenodesis isstillindicatedfrequently,butfrom2007to2011the arthro-scopictechniquewasmoreused.Theyobservedthatthemean ageofthepatientsrangedfrom30to59yearsandthatthe pro-cedurewastwiceasfrequentinmen.Rotatorcuffinjurywas themostcommonlyassociatedprimarydisorder.
Friedmanetal.,54inaretrospectivestudy,comparedthe
results of LHB tenotomy and subpectoral tenodesis, with anchors,inpatientsunder55years.Thefollowinggroupswere compared:musclestrength,rangeofmotion,residualpain, andpresenceofPopeyedeformity.Significantdifferenceswere observedinfunctionalscores,estheticdeformity,andmuscle strength.Theresidualpainindexwashigherinpatientswho underwenttenodesis.
Discussion
Accordingtotheliterature,themainsurgicalindicationsfor LHBlesions,otherthanfailureofconservativetreatment,are partial lesions affectingover 25% ofthe tendon diameter, longitudinalinjuries,instabilitieswithsubluxationormedial dislocation, association with subscapularis muscle tendon injury, hourglass biceps(described byBoileau et al.27), and
detachmentofthe glenoid labrum(SLAP lesions).Itisalso suggestedthatLHBproceduresshouldnotberoutinely indi-cated for the treatment of rotator cuff injuries. Themain techniquesdescribedforthesurgicaltreatmentofLHB disor-derswere:acromioplasty,debridement,reconstructionofthe bicepsreflectionpulley,tenotomy,andtenodesis.4,5,9–54
StudiesthatadvocatetheuseofLHBtenotomysuggestthat its mainadvantagesare the factthat it istechnically sim-plerandlowercost,withafasterrehabilitationandwithout risksrelatedtotheuseofsyntheticmaterials.Nonetheless, thechancesofPopeyedeformity,lossofsupinationforce,and muscularfatiguearehigherwhenthistechniqueisused.They could also cause biomechanical changes in the long term andleadtohumeralheadascensionandbiomechanical alter-ationsintheshoulder.4,27–32,34–38,40
ThestudiesthatadvocatetheuseofLHBtenodesissuggest thatthistechniqueprovidedalowerriskofPopeyedeformity, withacloser-to-normalbiomechanicalandanatomical resti-tutionandabetterreturntosportsactivities.However,itwas associatedwithahighercost,greatertechnicalcomplexity, greater risk ofresidual pain, and more delayed rehabilita-tion.
Several LHB tenodesistechniques, arthroscopic oropen, havebeendescribed,bothwithgoodresultsintheliterature. ThesitesdescribedforLHBfixationinthehumerusinclude the proximal portionof thebicipital groove, suprapectoral, subpectoral,or inthe softtissue, suchasinthe conjoined tendonandthetendonofthepectoralismajormuscle.Some authorshavesuggestedthatsuprapectoraltenodesisaswell astenodesis performeddistaltotheintertuberculargroove havebetterresultsregardingresidualpain.4,27–30,33,36,39–50,52,53
Regardingthetypeofmaterialused(interferencescrewand anchors)forLHBtenodesis,the retrievedstudiespresented divergencesintheirresults.Somebiomechanicalstudieshave suggested that interferencescrews are moreresistant and thatthemainchallengeoftenodesisistomaintainthe phys-iological tendon tension and length. The increase in LHB tensioncouldleadtofailureofitsfixationandresidualpain. Thedecreaseintensioncould leadtoPopeyedeformityand decreasedstrength.4,27–30,33,36,39–50,52,53
BecauseLHBdisordersare usuallyassociatedwithother shoulderconditions,theretrievedstudiesdifferonthebest resultsandthebesttechniques.Futurerandomizedclinical trialsmayprovidemoreconclusiveresults.4,6–8,14,24–54
Final
considerations
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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