Rev. bras. ortop. vol.50 número4

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Original

article

Measurement

of

the

tendon

of

the

biceps

brachii

after

tenotomy:

study

on

cadavers

夽

Anderson

Cunha

Machado,

Fabiano

Rebouc¸as

Ribeiro,

Samuel

Machado

Martins

_,

Rômulo

Brasil-Filho,

Antonio

Carlos

Tenor-Junior,

Miguel

Pereira

da

Costa

HospitaldoServidorPúblicoEstadualdeSãoPaulo,SãoPaulo,SP,Brazil

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Articlehistory:

Received28April2014 Accepted29July2014 Availableonline3July2015

Keywords:

Shoulderjoint Glenoidcavity Tenotomy

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Objective:Toevaluatetheinfluenceofelbowandforearmrangeofmotiononthedistal excursionofthelongheadofthebiceps(LHB).

Methods:ThedistalexcursionoftheLHBaftertenotomyoftheshouldersofeightcadavers wasascertainedbymeasuringthedistancebetweenapointmarkedoutontheLHB,3cm fromtheanterolateralborderoftheacromion,anditspositionatdifferentdegreesofelbow flexion,usingadigitalpachymeter.Themeasurementsatelbowflexionof135◦_,90◦_,45◦_and 0◦_{werenoted:theseangleswereestablishedusingagoniometer.Themeasurementswere} madewiththeforearminneutral,supinationandpronationpositions.

Results:DifferencesbetweenthemeanmeasurementsofthedistalexcursionoftheLHB (totalsample)wereobservedbetweenthedegreesofelbowflexion(p<0.01).However,no statisticaldifferenceswereobservedbetweenthedifferentforearmpositions,betweenthe sides,gendersandagesofthecadaversstudied.

Conclusion: Progressiveextensionoftheelbowcausedprogressivedistalexcursionofthe LHB,butwithoutinterferenceintheforearmposition,gender,sideorageofthecadavers studied.

©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.Allrightsreserved.

Mensurac¸ão

do

tendão

do

bíceps

braquial

após

tenotomia:

estudo

em

cadáveres

Palavras-chave:

Articulac¸ãodoombro Cavidadeglenoide Tenotomia

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Objetivo:Avaliarainfluênciadaamplitudedemovimentodocotoveloedoantebrac¸ona excursãodistaldacabec¸alongadobíceps(CLB).

Métodos:Verificou-seaexcursãodistaldacabec¸alongadobíceps(CLB)apóstenotomiaem ombrosdeoitocadáveres,pormeiodaaferic¸ãodadistânciaentreumpontodemarcadona cabec¸alongadobíceps(CLB)a3cmdabordaanterolateraldoacrômioemflexãomáximae

夽

WorkperformedwithintheShoulderandElbowGroup,OrthopedicsandTraumatologyService,HospitaldoServidorPúblicoEstadual, SãoPaulo,SP,Brazil.

∗ _{Correspondingauthor.}

E-mail:[email protected](S.M.Martins).

http://dx.doi.org/10.1016/j.rboe.2015.06.012

Foramanotadasasmedidasnosgrausdeflexãodocotovelo135,90 ,45 e0,estabelecidas comousodeumgoniômetro.Asmedidasforamtomadascomoantebrac¸oemposic¸ão neutra,supinac¸ãoepronac¸ão.

Resultados:Observou-sediferenc¸aentreasmédiasdasmedidasdaexcursãodistaldacabec¸a longadobíceps(CLB)(amostratotal)entreosgrausdeflexãodocotovelo(p<0,01).Todavia, nãofoiencontradadiferenc¸aestatísticaentrediferentesposic¸õesdoantebrac¸o,entreos lados,gêneroseidadesdoscadáveresestudados.

Conclusão: Aextensãoprogressivadocotoveloocasionouaexcursãodistalprogressivada cabec¸alongadobíceps(CLB),masseminterferênciadaposic¸ãodoantebrac¸o,gênero,lado eidadedoscadáveresestudados.

©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Todososdireitosreservados.

Introduction

Thelongheadofthetendonofthebicepsbrachiimuscle(LHB) isdevelopedataroundtheseventhtoeighthweekofgestation anditbecomesdifferentiatedstartingfromthemesoderm.It isdescribedascontinuouswiththelabrumoftheglenoidand thesupraglenoidtubercle,anditpassesanteriorlyand supe-riorlytotheheadofthehumerusbeforeenteringthebicipital groove.1,2_{Itisintra-articularandextrasynovialandslides} pas-sivelyovertheheadofhumerusduringabductionorrotation. Itslengthis9cmanditsdiameteris5–6mm.Itinnervationis throughanetworkofsensoryfibersofthesympathetic ner-voussystem.3–5

Thebicepsextendsfromthescapulatotheforearmand hasfunctionsrelatingtotheshoulderandelbow.Itsfunction relatingtotheelbowhasbeenwellestablishedandincludes bothflexionandsupination.Ontheotherhand,inrelationto theshoulder,althoughseveralfunctionshavebeenattributed, theexactroleoftheLHBremainsamatterofcontroversy.6 ElectromyographicanalyseshaveshownthattheLHBserves asastabilizerinunstablejoints,butnotinstableshoulders.7 Biomechanical studies have demonstrated that the tendon actsasadynamicdepressoroftheheadofthehumerus,but thishasnotbeenprovenclinically.8,9 _{Kuhnet al.}10 demon-strateditsimportanceasarestrictorofexternalrotationof theabductedarm.

Lesionsofthesuperiorglenoidthat involvetheLHB are called SLAP lesions (superior labrum, anterior and poste-rior).Theywerefirstdescribedatthebeginningofthe1990s by Snyder et al.11 _{The conservative or surgical treatment} forthese lesions hasbeen well established, but there has neverbeenaconsensusregardingthepostoperative rehabili-tationtreatment.Thereareprotocolsdescribedinthecurrent literature,12,13_{inwhichearlymobilityoftheextendedelbowis} avoidedbecauseofdoubtsregardingtheconsequent tension-ingoftheproximalLHBandsuperiorglenoidlabrum,which were reinserted during the operation. These actionscould causefailureofhealingandanewinjury.12,13

Theobjectiveofthisstudywastoevaluatetheinfluence oftherangeofmotionoftheelbowandforearmonthedistal excursionoftheLHB.

Methods

Thisstudywasapprovedbyourinstitution’sresearchethics committee (number: CAAE 19893114.6.0000.5463). Sixteen shouldersofeightcadaversobtainedfromtheDeath Verifi-cationServiceoftheUniversityofSãoPaulo(SVOC-USP)were dissected.Noneofthesecadaverspresentedanyfracturesof theupperlimbs,localdeformitiesorscarring.Thedissections wereperformedbymeansofananterolateralaccess measur-ing10cm(Fig.1A),followedbydissectionbetweentheanterior andlateraldeltoidmuscle(Fig.1B)soastoapproachand dis-secttheLHB(Fig.1C).

Usingasurgicalpen,alineperpendiculartotheLHBwas marked out,3cmdistallytotheanterolateralborderofthe acromion.TenotomyoftheLHBwasperformedatitsoriginin thesupraglenoidtubercle,withtheelbowatmaximum flex-ion.ThedistalexcursionoftheLHBwasverifiedbymeasuring the distance betweenthe linemarked out on the bicipital tendonandneedlesplacedattheedgeofthelinepreviously establishedontheLHB,usingadigitalpachymeter(LeeTools, Houston,USA)(Fig.1D),astheelbowwasextended. Measure-mentswerenotedatthefollowingdegreesofelbowflexion: 135◦_,90◦_,45◦_and0◦_{,whichwereestablishedusinga}

goniome-ter.Themeasurementsweremadewiththeforearminthe neutral,supinationandpronationpositions.

Statisticalanalysis

Tocomparetheresultsfromthemeasurementsonthe dis-tal excursion of the LHB, the Friedman test was used. To determinethemeasurementsbetweenwhichstatistically sig-nificantdifferencesoccurred,theWilcoxontestwasused.For allthetests,therejectionlevelforthehypothesisofnullity was0.05(significancelevelof95%).

Fig.1–Tenotomyprocedureonacadaver.(A)Markingouttheboneanatomicalparametersandaccessroute;(B)accessvia anterolateralroute;(C)dissectionoftheLHBfromitsgroovetoitsoriginintheglenoid;(D)measurementoftheexcursionof theLHBafterproximaltenotomy,withelbowflexionat135◦_,90◦_,45◦_and0◦_.

Results

Amongthe eightcadaversdissected, five were female and threeweremale.Therewereeightrightshouldersandeight leftshoulders(Table1).Themeanvalueforthedistal excur-sionoftheLHBwiththeforearmintheneutralpositionand at135◦_{ofelbowflexionwas1.41mm;at90}◦_{,13.97mm;at45}◦_,

18.01mm;andat0◦_{,22.53mm(Table2).Whenthese}

measure-mentsweremadewiththeforearmmovedintopronationand

supinationpositions,therewerenodifferencesinrelationto theabovemeasurements.

Comparisons between the measurements on the distal excursionoftheLHBshowedsignificantdifferences(p<0.001), consideringtheentiresample,atalldegreesofelbowflexion (Table2).Ontheotherhand,therewerenostatistical differ-encesbetweentherightandleftsides(Table3),betweenthe maleandfemalesexes(Table4)orbetweentheages(Table5), amongthecadaversstudied.

Table1–Measurements(inmm,usingadigitalpachymeter)ofthedistalexcursionatelbowflexionsof135◦_,90◦_,45◦

and0◦_{(anglesobtainedbymeansofagoniometer).}

Cadaver Age Sex Side Excursionat135◦ _{Excursionat90}◦ _{Excursionat45}◦ _Excursionat0◦

1 76 F R 1.51 17.59 19.08 25.62

L 1.45 15.16 21.16 25.76

2 72 F R 1.88 12.15 17.53 21.13

L 0.99 12.84 18.32 21.06

3 64 M R 1.25 13.13 19.06 23.07

L 1.66 14.25 20.15 23.99

4 75 F R 1.58 12.88 16.5 22.54

L 1.57 11.98 15.84 21.4

5 58 M L 1.48 14.85 16.41 21.63

R 1.52 14.23 17.02 20.73

6 72 F R 1.6 17.9 19.76 26.43

L 1.51 16.9 19.6 26.12

7 69 M R 1.27 12.14 17.16 21.19

L 1.5 13.13 18 21.77

8 88 F R 1.15 13 16.49 19.18

L 1.16 11.31 16.02 18.85

Table2–StatisticalanalysisonthemeasurementsofthedistalexcursionoftheLHBinrelationtothetotalsample.

Totalsample General

135◦ ₉₀◦ ₄₅◦ ₀◦

Mean 1.44 13.97 18.01 22.53

Median 1.51 13.13 17.77 21.70

Standarddeviation 0.22 2.03 1.64 2.41

Q1 1.27 12.67 16.50 21.11

Q3 1.57 14.93 19.21 24.40

N 16 16 16 16

IC 0.11 1.00 0.80 1.18

Side Mean Median Standarddeviation Q1 Q3 N IC pvalue

Excursionat135◦

Right 1.47 1.52 0.24 1.27 1.59 8 0.16 0.495

Left 1.42 1.49 0.22 1.38 1.53 8 0.16

Excursionat90◦

Right 14.13 13.07 2.33 12.70 15.07 8 1.61 0.875

Left 13.80 13.69 1.84 12.63 14.93 8 1.27

Excursionat45◦

Right 17.83 17.35 1.29 16.89 19.07 8 0.89 0.916

Left 18.19 18.16 2.00 16.31 19.74 8 1.39

Excursionat0◦

Right 22.49 21.87 2.49 21.03 23.71 8 1.72 0.834

Left 22.57 21.70 2.50 21.32 24.43 8 1.73

Table4–StatisticalanalysisonthemeasurementsofthedistalexcursionoftheLHBinrelationtosex.

Sex Mean Median Standarddeviation Q1 Q3 N IC pvalue

Excursionat135◦

Female 1.44 1.51 0.26 1.23 1.58 10 0.16 0.914

Male 1.45 1.49 0.16 1.32 1.52 6 0.13

Excursionat90◦

Female 14.17 12.94 2.49 12.32 16.47 10 1.54 0.828

Male 13.62 13.68 1.00 13.13 14.25 6 0.80

Excursionat45◦

Female 18.03 17.93 1.83 16.49 19.47 10 1.14 1.000

Male 17.97 17.58 1.41 17.06 18.80 6 1.13

Excursionat0◦

Female 22.81 21.97 2.93 21.08 25.73 10 1.82 0.828

Male 22.06 21.70 1.23 21.30 22.75 6 0.98

Table5–Statisticalanalysisonthemeasurementsofthe distalexcursionoftheLHBinrelationtoage.

Age

Corr pvalue

Excursionat135◦ _{−21.6% 0.422}

Excursionat90◦ _{−19.7% 0.466}

Excursionat45◦ _{−12.2% 0.653}

Excursionat0◦

−8.9% 0.742

Discussion

Thisstudyisinagreementwiththestudyconductedby Gram-stadetal.,14_{withevidenceofincreasingdistalexcursionofthe} LHBastheelbowisextended.Ontheotherhand,accordingto thoseauthors,notonlyelbowextensionbutalsopronationof theforearmwasassociatedwithincreasedtensionontheLHB, andonthesuperiorlabrumoftheglenoid.Inourobservations, nodifferencesindistalexcursionoftheLHBwereseenwith regardtothepositioningoftheforearm(pronationor supina-tion).Thisdifferenceinresultscanpossiblybeexplainedby thefactthatthoseauthors madetheirmeasurementswith theshoulderabductedat60◦_{,whereasinourstudy,the}

mea-surementsweremadewiththeshoulderadductedagainstthe body.

AccordingtoWilketal.,13_{inpostoperativetreatmentfor} SLAPlesions,activeandpassiveelbowextensionexercisesare indicatedstartinginthefirsttendaysaftertheoperation,only forpatientswhounderwentsimpledebridement(typesIand IIIofSnyder’sclassification).However,amongpatientswho underwentrepairstoSLAPlesions(typesIIandIVofSnyder’s classification),earlycompleteextensionoftheelbowandthe consequentproximalbicipitaltensioningshouldbeavoided. Thisguidanceisconcordantwiththefindingsfromourstudy, sincegreater distalexcursionoftheLHB aftertenotomyat itsorigin wasdemonstratedastheelbowwasprogressively extended.

Conclusions

AftertenotomyattheoriginoftheLHB,progressiveextension oftheelbowcausedprogressivedistalexcursionoftheLHB, butwithoutinterferencefromthepositionoftheforearmor fromthesex,sideorageofthecadaversstudied.

Conflicts

of

interest

Acknowledgements

TheauthorsthanktheorthopedicsteamatHospitaldo Servi-dorPúblico Estadual,SãoPaulo,andthe teamoftheDeath VerificationServicefortheirsupportincarryingoutthisstudy.

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1. GardnerE,GrayDJ.Prenataldevelopmentofthehuman shoulderandacromioclavicularjoints.AmJAnat. 1953;92(2):219–76.

2. JobeC.Grossanatomyoftheshoulder.In:RockwoodC,editor. Theshoulder.Philadelphia:Elsevier;2009.

3. HitchcockHH,BechtolCO.Painfulshoulder:observationson theroleofthetendonofthelongheadofthebicepsbrachiiin itscausation.JBoneJointSurgAm.1948;30(2):263–73.

4. AlpantakiK,McLaughlinD,KaragogeosD,HadjipavlouA, KontakisG.Sympatheticandsensoryneuralelementsinthe tendonofthelongheadofthebiceps.JBoneJointSurgAm. 2005;87(7):1580–3.

5. BeyMJ,EldersGJ,HustonLJ,KuhnJE,BlasierRB,SoslowskyLJ. Themechanismofcreationofsuperiorlabrum,anterior,and posteriorlesionsinadynamicbiomechanicalmodelofthe shoulder:theroleofinferiorsubluxation.JShoulderElbow Surg.1998;7(4):397–401.

6.SethiN,WrightR,YamaguchiK.Disordersofthelongheadof thebicepstendon.JShoulderElbowSurg.1999;8(6):644–54.

7.KimSH,HaKI,KimHS,KimSW.Electromyographicactivityof thebicepsbrachiimuscleinshoulderswithanterior

instability.Arthroscopy.2001;17(8):864–8.

8.KumarVP,SatkuK,BalasubramaniamP.Theroleofthelong headofbicepsbrachiiinthestabilizationoftheheadofthe humerus.ClinOrthopRelatRes.1989;244:172–5.

9.WarnerJJ,McMahonPJ.Theroleofthelongheadofthebiceps brachiiinsuperiorstabilityoftheglenohumeraljoint.JBone JointSurgAm.1995;77(3):366–72.

10.KuhnJE,HustonLJ,SoslowskyLJ,ShyrY,BlasierRB.External rotationoftheglenohumeraljoint:ligamentrestraintsand muscleeffectsintheneutralandabductedpositions.J ShoulderElbowSurg.2005;141SupplS:39S–48S.

11.SnyderSJ,KarzelRP,DelPizzoW,FerkelRD,FriedmanMJ. SLAPlesionsoftheshoulder.Arthroscopy.1990;6(4):274–9.

12.AndrewsJR,CarsonWG,McLeodWD.Glenoidlabrumtears relatedtothelongheadofthebiceps.AmJSportsMed. 1985;13(5):337–41.

13.WilkKE,ReinoldMM,DugasJR,ArrigoCA,MoserMW, AndrewsJR.Currentconceptsintherecognitionand treatmentofsuperiorlabral(SLAP)lesions.JOrthopSports PhysTher.2005;35(5):273–91.