Translation and Cultural Adaptation to Portuguese of the Long Head of Biceps Tendon Score / Tradução e adaptação cultural à língua portuguesa do Long Head Biceps Score

Abstract Objective To translate and culturally adapt the Long Head of Biceps Tendon (LHB) score into Brazilian Portuguese. Methods The process involved translations by professionals fluent in the target language, followed by independent back translations. Next, a committee compared the original and translated versions, pretested the final version, and concluded it. Results We translated and adapted the questionnaire according to the proposed methodology. In the first version in Portuguese (VP1) there was divergence regarding the translation of twelve terms. Compared to the original version, the back translation of VP1 presented eight diverging terms. A committee prepared a second version in Portuguese (VP2) and applied it to a pretest group consisting of 30 participants. Finally, we conceived the third version in Portuguese, called LHB-pt. Conclusion The translation and cultural adaptation into Brazilian Portuguese of the LBH score was successfully accomplished.

Fascia lata autograft bridging combined with long head of biceps tendon transposition for irreparable massive rotator cuff tear / 中华骨科杂志

Objective:To investigate the early clinical effect of fascia lata autograft bridging combined with the long head of biceps tendon transposition for treatment of irreparable massive rotator cuff tear.Methods:All of 31 cases of massive irreparable rotator cuff tear treated in our hospital from March 2016 to March 2020 were analyzed retrospectively. Among them, 17 cases (10 males, 7 females) were repaired with fascia lata autograft bridging under arthroscopy (patch group), the average age was 61.47±6.63 (ranging from 51 to 72) and 14 cases (4 males, 10 females) were repaired with fascia lata autograft bridging combined with the long head of biceps tendon transposition (combined group), the average age was 62.57±6.11 (ranging from 53 to 71). The operation time, intraoperative blood loss, postoperative complications, visual analogue scale (VAS) of pain before operation, at 1 week and 12 months after operation, Constant-Murley score of shoulder joint and American Association of shoulder and elbow Surgeons (ASES) score before operation, at 6 months and 12 months after operation were compared between the two groups. The outcome of rotator cuff healing was evaluated by MRI 1 year after operation.Results:All patients were followed up for 12-27 months (mean 18.33 ±6.8 months). There was no perioperative complication, and there was no significant difference in operation time between the two groups ( P>0.05) . The VAS score in the patch group was significantly higher than the combined group 1 week after operation ( t=2.09, P=0.048) , and there was no significant difference in VAS score 12 months after operation between the two groups. Constant-Murley score and ASES score in the combined group were significantly higher than the patch group at 6 months after operation ( t=5.23, P<0.001; t=4.45, P<0.001) , and there was no significant difference in Constant score and ASES score between the two groups at 12 months after operation. Constant score and ASES score in the two groups were significantly higher than those before operation. One year after operation, the MRI of the affected shoulder showed that the incidence of autograft patch thinning (Sugaya grade III) was 52.94%, the autograft patch structure failure rate (Sugaya grade IV and V) was 17.65% in the patch group, the autograft patch thinning rate (Sugaya grade III) was 35.71%, and the structural failure rate (Sugaya grade IV and V) was 7.14% in the combined group. The difference was statistically significant (χ 2=7.12, P=0.028) . Conclusion:Fascia lata autograft patch bridging combined with long head of biceps tendon transposition technique for treatment of irreparable massive rotator cuff tear has less pain 1 week after operation and better recovery of shoulder function half a year after operation. MRI showed better patch healing 1 year after operation.

Correlation between Elbow Flexor Muscle Strength and Needle Electromyography Parameters after Musculocutaneous Nerve Injury / 法医学杂志

OBJECTIVES@#To explore the changes of elbow flexor muscle strength after musculocutaneous nerve injury and its correlation with needle electromyography (nEMG) parameters.@*METHODS@#Thirty cases of elbow flexor weakness caused by unilateral brachial plexus injury (involving musculocutaneous nerve) were collected. The elbow flexor muscle strength was evaluated by manual muscle test (MMT) based on Lovett Scale. All subjects were divided into Group A (grade 1 and grade 2, 16 cases) and Group B (grade 3 and grade 4, 14 cases) according to their elbow flexor muscle strength of injured side. The biceps brachii of the injured side and the healthy side were examined by nEMG. The latency and amplitude of the compound muscle action potential (CMAP) were recorded. The type of recruitment response, the mean number of turns and the mean amplitude of recruitment potential were recorded when the subjects performed maximal voluntary contraction. The quantitative elbow flexor muscle strength was measured by portable microFET 2 Manual Muscle Tester. The percentage of residual elbow flexor muscle strength (the ratio of quantitative muscle strength of the injured side to the healthy side) was calculated. The differences of nEMG parameters, quantitative muscle strength and residual elbow flexor muscle strength between the two groups and between the injured side and the healthy side were compared. The correlation between elbow flexor manual muscle strength classification, quantitative muscle strength and nEMG parameters was analyzed.@*RESULTS@#After musculocutaneous nerve injury, the percentage of residual elbow flexor muscle strength in Group B was 23.43% and that in Group A was 4.13%. Elbow flexor manual muscle strength classification was significantly correlated with the type of recruitment response, and the correlation coefficient was 0.886 (P<0.05). The quantitative elbow flexor muscle strength was correlated with the latency and amplitude of CMAP, the mean number of turns and the mean amplitude of recruitment potential, and the correlation coefficients were -0.528, 0.588, 0.465 and 0.426 (P<0.05), respectively.@*CONCLUSIONS@#The percentage of residual elbow flexor muscle strength can be used as the basis of muscle strength classification, and the comprehensive application of nEMG parameters can be used to infer quantitative elbow flexor muscle strength.

Analysis of Nerve Endings in the Superior Labrum-Biceps Complex by Fluorescence Immunohistochemistry and Confocal Laser Microscopy / Análise de terminações nervosas no complexo labrum-bíceps superior usando imunohistoquímica de fluorescência e microscopia a laser confocal

Abstract Objectives The capsuloligamentous structures of the shoulder work as static stabilizers, together with the biceps and rotator cuff muscles, increasing the contact surface of the glenoid cavity. Free nerve endings and mechanoreceptors have been identified in the shoulder; however, there are a few studies that describe the presence of these nerves in the biceps' insertion. The present study aimed to describe the morphology and distribution of nerve endings using immunofluorescence with protein gene product 9.5 (PGP 9.5) and confocal microscopy. Methods Six labrum-biceps complexes from six fresh-frozen cadavers were studied. The specimens were coronally cut and prepared using the immunofluorescence technique. In both hematoxylin and eosin (H&E) and immunofluorescence, the organization of the connective tissue with parallel collagen fibers was described. Results In the H&E study, vascular structures and some nerve structures were visualized, which were identified by the elongated presence of the nerve cell. All specimens analyzed with immunofluorescence and confocal microscopy demonstrated poor occurrence of morphotypes of sensory corpuscles and free nerve endings. We identified free nerve endings located in the labrum and in the bicipital insertion, and sparse nerve endings along the tendon. Corpuscular endings with fusiform, cuneiform, and oval aspect were identified in the tendon. Conclusion These findings support the hypothesis that the generation of pain in the superior labral tear from Anterior to posterior (SLAP) lesions derives from the more proximal part of the long biceps cord and even more from the upper labrum. Future quantitative studies with a larger number of specimens may provide more information on these sensory systems.

Resumo Objetivos As estruturas capsulo-ligamentares do ombro funcionam como estabilizadores estáticos, juntamente com os músculos do bíceps e do manguito rotador, aumentando a superfície de contato da cavidade glenoide. Terminações nervosas livres e mecanorreceptores foram identificados no ombro; no entanto, existem alguns estudos que descrevem a presença desses nervos na inserção do bíceps. Este estudo teve como objetivo descrever a morfologia e distribuição de terminações nervosas utilizando imunofluorescência com protein gene product 9.5 (PGP 9.5) e microscopia confocal. Métodos Foram estudados seis complexos labrum-bíceps de seis cadáveres congelados frescos. Os espécimes foram cortados coronalmente e preparados pelo método de imunofluorescência. Tanto em hematoxilina e eosina (H&E) quanto em imunofluorescência, foi descrita a organização do tecido conjuntivo com fibras paralelas de colágeno. Resultados No estudo de H&E, foram visualizadas estruturas vasculares e algumas estruturas nervosas, que foram identificadas pela presença alongada da célula nervosa. Todas as amostras analisadas com imunofluorescência e microscopia confocal demonstraram baixa ocorrência de morfotipos de corpúsculos sensoriais e terminações nervosas livres. Identificamos terminações nervosas livres localizadas no labrum, inserção bicipital e terminações nervosas esparsas ao longo do tendão. Terminais corpusculares com aspecto fusiforme, cuneiforme e oval foram identificados no tendão. Conclusão Esses achados corroboram a hipótese de que a geração de dor nas lesões labrais superiores de anterior a posterior (SLAP, na sigla em inglês) deriva da parte mais proximal do cabo longo do bíceps e ainda mais do labrum superior. Estudos quantitativos futuros com um número maior de espécimes podem fornecer mais informações sobre esses sistemas sensoriais.

Six asymmetric bilateral additional heads of biceps brachii muscle observed in a cadaver / Seis cabezas adicionales bilaterales asimétricas del músculo bíceps braquial observadas en un cadáver

SUMMARY: Anatomic variation of the biceps brachii muscle (BBM) is frequently observed; its pattern is diverse and clinically important. During the educational dissection of a 78-year-old Korean male cadaver, six additional asymmetrical heads of the biceps brachii muscle (BBM) were found on both sides. On the right side, two additional heads originated from the humerus; the musculocutaneous nerve passed between these heads and the short head of the BBM. Four additional heads were found on the left side, anterior to the BBM, one of which originated from the pectoralis major muscle. Posterior to the BBM, two heads of tendons originated from the coracobrachialis muscle and one head of the muscle belly originated from the humerus. The left musculocutaneous nerve pierced the coracobrachialis muscle and continued distally passing between the short head of the BBM and the additional heads located posterior to the BBM. It then gave off the variant musculocutaneous nerve to the median nerve. On both sides, the short and long heads of the BBM had normal origins, insertions, and courses. This novel variation has various clinical and embryological implications.

RESUMEN: Con frecuencia se observa una variación anatómica del músculo bíceps braquial (MBB); su patrón es diverso y clínicamente importante. Durante la disección de un cadáver masculino coreano de 78 años, se encontraron seis cabezas asimétricas adicionales del músculo bíceps braquial en ambos lados. En el lado derecho, dos cabezas adicionales se originaban en el húmero; el nervio musculocutáneo atravesaba entre estas cabezas y la cabeza corta del MBB. Se encontraron cuatro cabezas adicionales en el lado izquierdo, anterior al MBB, una de las cuales se originaba en el músculo pectoral mayor. Posterior al MBB, dos cabezas tendinosas se originaban en el músculo coracobraquial y una cabeza de vientre muscular se originaba en el húmero. El nervio musculocutáneo izquierdo perforaba el músculo coracobraquial y continuaba distalmente pasando entre la cabeza corta del MBB y las cabezas adicionales ubicadas por detrás del MBB. Luego emitía la variante el nervio musculocutáneo al nervio mediano. En ambos lados, las cabezas corta y larga del MBB tenían orígenes, inserciones y trayectos normales. Esta nueva variación tiene varias implicaciones clínicas y embriológicas.

Ruptura de bíceps braquial distal en paciente con COVID-19 / Distal biceps brachii rupture in a patient with COVID-19

Resumen: Introducción: La lesión del tendón distal del bíceps se presenta comúnmente en pacientes masculinos entre la quinta y sexta década de la vida. El mecanismo de la lesión es una contracción excéntrica con el codo en flexión de 90o. Para su tratamiento quirúrgico, en la literatura se describen varias opciones con diferentes abordajes, tipo de sutura a utilizar y diversos métodos de fijación de la reparación del tendón distal de bíceps. Las manifestaciones clínicas musculoesqueléticas del COVID-19 son fatiga, mialgia, artralgia, pero los efectos musculoesqueléticos del COVID-19 continúan siendo poco claros. Caso clínico: Paciente masculino de 46 años, COVID-19 positivo, con una lesión aguda del tendón distal del bíceps y secundaria a un trauma mínimo, sin otros factores de riesgo. El paciente fue tratado quirúrgicamente siguiendo las guías ortopédicas y de seguridad para el paciente y el personal médico debido a la pandemia COVID-19. El procedimiento quirúrgico de la técnica de double tension slide (DTS) con una sola incisión es una opción confiable y en nuestro caso de una baja morbilidad, con pocas complicaciones y una buena opción cosmética. Conclusión: El manejo de patologías ortopédicas en pacientes COVID-19 positivos va en aumento, así como las implicaciones éticas y ortopédicas del manejo de estas lesiones y/o el retraso de su atención durante la pandemia.

Abstract: Introduction: Distal biceps tendon injury commonly occurs in male patients between the fifth and sixth decade of life. The mechanism of the injury is an eccentric contraction with the elbow in flexion of 90 degrees. For its surgical treatment, several options have been described in the literature with different approaches, type of suture to be used and various methods of fixing the repair of the distal biceps tendon. The musculoskeletal clinical manifestations of COVID-19 are fatigue, myalgia, arthralgia, but the musculoskeletal effects of COVID-19 remain unclear. Case report: 46-year-old COVID-19 positive male patient with acute distal biceps tendon injury and secondary to minimal trauma, with no other risk factors. The patient was treated surgically following orthopedic and safety guidelines for the patient and medical staff due to the COVID-19 pandemic. The surgical procedure of the double tension slide (DTS) technique with a single incision in a reliable option and our case of a low morbidity, few complications and a good cosmetic option. Conclusion: The management of orthopedic pathologies in COVID-19 positive patients is increasing as well as the ethical and orthopedic implications of the management of these injuries and/or the delay of their care during the pandemic.

Biceps tenotomy or tenodesis in association with rotator cuff repair: is there an influence on functional results? A retrospective cohort study

ABSTRACT BACKGROUND: Instability or tears of the long head of the biceps tendon (LHBT) may be present in more than 35% of rotator cuff repairs (RCR). OBJECTIVE: To compare clinical results from patients undergoing arthroscopic RCR, according to the procedure performed at the LHBT. DESIGN AND SETTING: Retrospective cohort study designed at the shoulder and elbow clinic of Instituto de Ortopedia e Traumatologia, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Brazil. METHODS: Functional results among patients were compared using the American Shoulder and Elbow Surgeons (ASES) and University of California Los Angeles (UCLA) scales, according to the LHBT approach adopted: no procedure, tenotomy or tenodesis. RESULTS: We evaluated 306 shoulders (289 patients): 133 underwent no procedure at the LHBT, 77 tenotomy and 96 tenodesis. The ASES scale at 24 months showed no difference (P = 0.566) between the groups without LHBT procedure (median 90.0; interquartile range, IQR 29), tenotomy (median 90.0; IQR 32.1) or tenodesis (median 94.4; IQR 22.7); nor did the UCLA scale (median 33; IQR 7 versus median 31; IQR 8 versus median 33; IQR 5, respectively, P = 0.054). The groups differed in the preoperative functional assessment according to the ASES and UCLA scale, such that the tenodesis group started from higher values. However, there was no difference in pre and postoperative scores between the groups. CONCLUSION: Tenodesis or tenotomy of the LHBT, in the sample analyzed, did not influence the clinical results from RCR, as assessed using the ASES and UCLA scales.

Acute distal biceps repair using double incision technique: results of a standardized home rehabilitation protocol / Reparación aguda del bíceps distal mediante técnica de doble incisión: resultados de un protocolo estandarizado de rehabilitación domiciliaria

Abstract: Introduction: Distal biceps tear can lead to loss in flexion and supination strength. Early repair in active patients is recommended. Postoperative rehabilitation varies according to surgeon experience and surgical technique used. The aim of this study is to present the results of a series of patients using a standardized home rehabilitation protocol after a distal biceps repair with double incision technique. Material and methods: This is a retrospective case study. We registered 21 patients with distal biceps tear, surgically treated using a double incision technique and transosseous suture fixation, followed by a home-based exercise program. Patients were evaluated using MEPS score, DASH questionnaire, and the subjective/objective scoring system of Andrews and Carson. Radiographic assessment was done for heterotopic bone formation. Results: Mean MEPS was 95 (range 70 to 100), DASH score 0.4 (range 0 to 4.2), and subjective and objective Andrews and Carson score was 99 (range 90 to 100). Two patients developed heterotopic ossifications. Range of motion was recovered in every patient. All patients went back to their previous surgical activities. Conclusions: Patients treated with double incision repair for distal biceps tear can undergo a home rehabilitation protocol, expecting normal range of motion and strength recover.

Resumen: Introducción: Las lesiones del bíceps distal pueden generar pérdida de fuerza de flexión y supinación. En pacientes activos, se recomienda la reparación temprana. La rehabilitación postoperatoria varía de acuerdo con la experiencia del cirujano y la técnica quirúrgica utilizada. El objetivo del estudio es presentar los resultados de una serie de pacientes utilizando un protocolo de rehabilitación estandarizado posterior a la reparación del bíceps distal mediante la técnica de doble abordaje. Material y métodos: Este es un estudio retrospectivo. Se registraron 21 pacientes con lesión del bíceps distal, que fueron tratados quirúrgicamente utilizando un doble abordaje y fijación transósea con suturas, seguido de un programa de ejercicios en el domicilio. Los pacientes fueron evaluados utilizando el score de MEPS, el cuestionario DASH y el puntaje subjetivo/objetivo de Andrews y Carson. Se realizaron radiografías para evaluar osificaciones heterotópicas. Resultados: La media del MEPS fue 95 (rango de 70 a 100), del DASH 0.4 (rango 0 a 4.2) y del score de Andrews y Carson fue 99 (rango 95 a 100). Dos pacientes desarrollaron calcificaciones heterotópicas. El rango de movilidad se recuperó en todos los pacientes. Todos volvieron a sus actividades previas a la cirugía. Conclusiones: Los pacientes que fueron tratados mediante un doble abordaje por lesiones del bíceps distal pueden realizar un protocolo de ejercicios en su domicilio, siendo esperable un rango de movilidad normal y recuperación de la fuerza muscular.

Evaluation of Biceps Tenotomy or Tenodesis on Fatty Infiltration of the Biceps Muscle / Avaliação da tenotomia ou tenodese bicipital na infiltração gordurosa do músculo bíceps

Abstract Objective The objective of the present study was to determine whether there is fatty infiltration (FI) of the biceps brachii muscle mass after tenotomy or tenodesis for the treatment of tendon injuries in the long head of the biceps and to establish a relationship between FI with changes in the length of muscle fibers. Methods Clinical and imaging analysis of 2 groups of patients (biceps tenodesis [16 patients] and biceps tenotomy [15 patients]). In both groups, we compared the findings on the contralateral side of each patient (control group). All patients had undergone unilateral biceps tenodesis or tenotomy, with postoperative follow-up of > 1 year. Magnetic resonance imaging (MRI) was performed on both arms of each patient following a specific protocol. Strength of elbow flexion was measured with a manual dynamometer, and the results were subjected to statistical analysis. Results The mean postoperative period before the MRI was 5 years, and no case of FI was observed in the anterior compartment of either arm of the evaluated patients. Seven patients had moderate or severe deformity in the operated arm. We found no significant relationship between arm deformity (p = 0.077), flexion strength percentage (p = 0.07) or pain on palpation of the bicipital groove (p = 0.103). Conclusion None of the evaluated patients had evidence of FI in the muscle mass of the anterior arm compartment after the procedures. It was not possible to establish a correlation between the discrepancy of the biceps muscle length measured by MRI and the presence of FI in the anterior compartment of the arm.

Resumo Objetivo O objetivo do presente estudo foi determinar a existência de infiltração gordurosa (IG) na massa muscular do bíceps braquial após a tenotomia ou tenodese para tratamento de lesão no tendão da cabeça longa do bíceps e estabelecer uma relação entre a IG e alterações no comprimento das fibras musculares. Métodos Análise clínica e de imagens de 2 grupos de pacientes (submetidos à tenodese do bíceps [16 indivíduos] ou tenotomia do bíceps [15 indivíduos]). Nos dois grupos, os achados foram comparados àqueles do lado contralateral de cada indivíduo (grupo controle). Todos os pacientes foram submetidos à tenodese ou tenotomia unilateral do bíceps, com acompanhamento pós-operatório > 1 ano. Exames de ressonância magnética (RM) foram realizados em ambos os braços de cada paciente de acordo com um protocolo específico. A força de flexão do cotovelo foi medida com dinamômetro manual e os resultados foram submetidos à análise estatística. Resultados O período pós-operatório médio antes da realização da RM foi de 5 anos, e nenhum caso de IG foi observado no compartimento anterior de ambos os braços dos pacientes avaliados. Sete pacientes apresentaram deformidade moderada ou grave no braço operado. Não houve relação significativa entre deformidade do braço (p = 0,077), percentual de força de flexão (p = 0,07) ou dor à palpação do sulco bicipital (p = 0,103). Conclusão Nenhum dos pacientes avaliados apresentou evidência de IG na massa muscular do compartimento anterior do braço após os procedimentos. Não foi possível estabelecer uma correlação entre a discrepância do comprimento do músculo bíceps, medido à RM, e a presença de IG no compartimento anterior do braço.

Tenodesis intrarticular del bíceps y reparacion simultanea de lesiones de subescapular laffosse I y II con anclaje sin nudos. Nota técnica / Intraarticular biceps tenodesis and simultaneous subscapularis lafosse type I or II repair with knotless anchor. Technical Note

La tendinopatía de la porción larga del Bíceps es causa frecuente de dolor en el hombro. Usualmente esta patología se relaciona con tendinopatía y lesiones del manguito rotador comprometiendo con mayor frecuencia el tendón del subescapular. El diagnóstico de esta entidad es difícil tanto clínica como radiológicamente, y la precisión diagnóstica de las lesiones parciales del Bíceps en Resonancia Nuclear Magnética (RMN) es relativamente baja. El objetivo de la nota técnica es presentar una Tenodesis intra-articular de la porción larga del Bíceps utilizando un anclaje óseo sin nudos, el cual sirve a su vez para reinsertar lesiones de tendón subescapular Laffosse tipo I y II con suturas adicionales.

Long head biceps tendinopathy is a common cause of shoulder pain. Usually, this pathology is related to both, tendinopathy and rotator cuff injuries, most frequently involving the subscapularis tendon. The diagnosis of this entity is difficult clinically and radiologically, and the diagnostic sensitivity and specificity of partial biceps injuries in Magnetic Resonance imaging (MRI) is relatively low. The aim of the technical note is to present an intra-articular tenodesis of the long head of the biceps using a knotless bone anchor, which serves once to reinsert type I and II Laffosse subscapular tendon injuries with additional sutures.

The relevant anatomy of the biceps tendon when performing tenodesis in Filipino cadaveric specimens

BACKGROUND@#Biceps tenodesis is a technique frequently performed in shoulder surgeries. Various techniques have been described, but there is no consensus on which technique restores the length-tension relationship. Restoration of the physiologic length-tension relationship has been correlated to better functional outcomes, such as decreased incidence of residual pain or weakness of the biceps. The objective of this study was to measure the anatomic relationship of the origin of the biceps tendon with its zones in the upper extremity. This would provide an anatomic guide or an acceptable placement of the tenodesis to reestablish good biceps tension during surgery@*METHODS@#The study used nine adult cadavers (five males, four females) from the [withheld for blinded review]. Nine shoulder specimens were dissected and markers were placed at five points along each biceps tendon: (1) Labral origin (LO) (2) Superior bicipital groove (SBG) (3) Superior border of the pectoralis tendon (SBPMT) (4) Musculotendinous junction (MTJ) and (5) Inferior border of the pectoralis tendon (IBPMT). Using the origin of the tendon as the initial point of reference, measurements were made to the four subsequent sites. The humeral length was recorded by measuring the distance between the greater tuberosity and the lateral epicondyle as well as the tendon diameter at the articular surface.@*RESULTS@#The intraclass correlation coefficient was excellent across all measures. A total of nine cadavers were included. Mean age of patients was 66.33 years old, ranging from 52-82 years old. These were composed of five male and four female cadavers. The mean tendon length was 24.83mm ± 4.32 from the origin to the superior border of the bicipital groove, 73.50mm ± 6.96 to the Superior Border Pectoralis Major Tendon, 100.89mm ± 6.88 to the Musculotendinous Junction, and 111.11mm ± 7.45 to the Inferior Border Pectoralis Major Tendon. The mean tendon diameter at the articular origin was 6.44mm ± 1.76.@*CONCLUSION@#This study provided measurement guidelines that could restore the natural length-tension relationship during biceps tenodesis using the interference screw technique in Filipinos. A simple method of restoring a normal length-tension relationship is by doing tenodesis close to the articular origin and creating a bone socket of approximately 25mm in depth, using the superior border of the bicipital groove as a landmark.

The “POPEYE SIGN” – A Classical but Rare Case

@#Isolated biceps tendon rupture is rarely reported at primary care level. A 78-year-old man presented with deformity over his right mid arm for one week, following a low impact trauma over his right shoulder six weeks prior. Physical examination revealed the classical sign of rupture of the long head of biceps tendon (LHBT) which showed bulging of his right biceps muscle, resembling the famous cartoon character, “Popeye The Sailorman”. Diagnosis of rupture of LHBT was made in the primary care clinic without the need of imaging modality based on the identification of the “Popeye Sign”. Diagnosis and condition have been explained well to patient and caretaker without the need for inappropriate investigation and procedures. Conservative treatment approach was opted. His condition was stable without new active complaints on subsequent follow up. This case proved that stable ruptures of LHBT are still possible to be managed at primary care level.

Curative effect of intra-tendon sheath hyaluronidase injection guided by ultrasound in treating biceps brachii longitendosynovitis / 中国医师杂志

Objective:To observe the effect of hyaluronidase injection into tendon sheath under muscle bone ultrasound guidance in the treatment of tenosynovitis of long head of biceps brachii.Methods:134 patients with tenosynovitis of the long head of biceps brachii treated in SSL Central Hospital of Dongguan from April 2019 to April 2020 were selected as the research objects. All patients were randomly divided into ordinary injection group and ultrasound-assisted injection group, 67 cases in each group. The general injection group was treated with intra-articular injection of hyaluronidase, and the ultrasound-assisted injection group was treated with intra-tendon sheath injection of hyaluronidase under the guidance of muscle and bone ultrasound. Visual Analog Scales (VAS) score, active flexion joint motion (AFROM), shoulder range of motion (ROM), functional score, flexion strength score, nuclear magnetic resonance imaging (MRI) and local tenosynovitis of the long head of biceps brachii (TLHBB)were measured to evaluate the clinical effect and postoperative complications after treatment.Results:There was no significant difference in gender, age, course of disease, periarthritis of shoulder and disuse atrophy of muscles around shoulder between ordinary injection group and ultrasound-assisted injection group ( P>0.05). After treatment, the AFROM, ROM, function score, forward flexion strength score, and middle wedge angle (MWA) of the two groups were significantly higher than those before treatment ( P<0.05), while the VAS score, humeral head diameter (HHD), biceps long head tendon diameter (BTD), and TLBBB were significantly lower than those before treatment ( P<0.05). The AFROM, ROM, function score, and forward flexion strength score, MWA of the ultrasound-assisted injection group were significantly higher than those of the ordinary injection group ( P<0.05), and the VAS score, HHD, BTD, and TLHBB were significantly lower than those of the ordinary injection group ( P<0.05). The total effective rate of the ultrasound-assisted injection group was higher than that of the ordinary injection group (97.01% vs 85.07%, P<0.05). Conclusions:Intra-tendon sheath hyaluronidase injection guided by ultrasound can effectively treat tenosynouitis of the long head of biceps brachii, relieve shoulder pain and improve shoulder motion.

Common origin tendon of the biceps femoris and semitendinosus muscles, functional and clinical relevance / Tendón de origen común de los músculos bíceps femoral y semitendinoso, relevancia funcional y clínica

SUMMARY: The injury of Biceps Femoris long head (BFlh) and Semitendinosus (ST) is caused by over-stretch of the muscles at the back of the thigh. This condition encompasses almost one third of sports-related injuries and has severe consequences, such as pain and weakness of the muscles. This injury is related namely to quick and demanding activities, such as short distance sprinting in a limited time period. The Common Origin Tendon (COT) for these two muscles is affected in these injuries. This tendon is formed by the BFlh and ST muscles which together have a common origin in the ischial tuberosity. Given the lack of complete knowledge about the detailed structure of the COT, we dissected cadaveric limbs, describing their morphological characteristics, and discussing its functional and clinical implications.: Thirty-five human cadaveric lower limbs were dissected after fixation to analyze the morphology of the COT, focusing on their volume and muscular/tendinous proportion. We identified two subtypes of COT. The most frequent was the musculotendinous type, in which the origin of the BFlh was mainly tendinous, while the ST muscle was mainly muscular (91.4%). In the tendinous type both muscles had a tendinous origin (8.6%). In the musculotendinous type, the ST muscle ends with a microscopic connective tissue that extend into the ischial tuberosity. We conclude that there is a variability in the anatomical presentations of the COT, and we propose that this will correspond with biomechanical differences in the risks and the response to regional injuries. The connective tissue between the COT and the neighbouring structures could be a risk factor for adhesion tearing.

RESUMEN: Los desgarros de los músculos bíceps femoral cabeza larga (BFcl) y semitendinoso (ST) son causados por una tensión excesiva durante actividades que implican amplios rangos de movimiento en velocidad. Alcanzan casi a un tercio de las lesiones deportivas y tienen graves consecuencias competitivas, además generan dolor y debilidad muscular. El tendón de origen común (TOC) de estos dos músculos se ve afectado en estas lesiones. Este tendón se encuentra formado por el BFcl y el ST, originándose juntos en la tuberosidad isquiática. Debido a la falta de conocimiento completo y detallado de este tendón, se realizó un estudio cadavérico, describiendo sus características morfológicas y discutiendo sobre sus implicaciones funcionales y clínicas. Se practicó la disección anatómica de 35 miembros inferiores, lo que permitió describir la morfología del TOC, focalizando en su volumen y proporciones musculo-tendinosas. La conformación morfológica del TOC fue de 2 tipos: la musculotendinosa, donde el BFcl tenía una estructura tendinosa y el ST tenía una estructura muscular (91,4 %). La conformación tendinosa, donde ambos músculos tenían estructuración tendinosa (8,6 %). Cuando la conformación era musculotendinosa, el ST terminaba con un tejido conjuntivo microscópico, que se extendía hasta la tuberosidad isquiática. La conformación morfológica del TOC del BFcl y ST tuvo una presentación variable, lo cual podría tener implicación en su comportamiento biomecánico, y ser un factor de riesgo de lesiones. Además el tejido conjuntivo situado entre este tendón y las estructuras anatómicas vecinas podría ser un factor de riesgo de lesiones por adherencia.

Supraspinatus Muscle Tendon Lesion and Its Relationship with Long Head of the Biceps Lesion / Lesão do tendão do músculo supraespinal e sua relação com a lesão do tendão da cabeça longa do bíceps

Abstract Objective To identify the clinical, radiological, and arthroscopic correlation of long head of the biceps tendon injuries and their influence on pain when associated with rotator cuff injuries. Methods Between April and December 2013, 50 patients were evaluated, including 38 (76%) women and 12 (24%) men, with a mean age of 65.1 years old. The patients were operated by the Shoulder and Elbow Group, Discipline of Sports Medicine, Orthopedics and Traumatology Department, Universidade Federal de São Paulo. The subjects underwent repair of the rotator cuff lesion with clinical, radiological and/or arthroscopic evidence of involvement of the long head of the biceps tendon. Results An association between pain at palpation of the intertubercular groove of the humerus and high-grade partial lesions (partial rupture of the tendon affecting more than 50% of its structure) was observed at the arthroscopy (p = 0.003). There was also an association between the high-grade lesion of the long head of the biceps and injury to the supraspinatus muscle tendon (p < 0.05). For each centimeter of the supraspinatus muscle tendon injury, the patient presented a 1.7 higher probability of having a high-grade lesion at the long head of the biceps. Conclusion Pain at the anterior shoulder region during palpation of the intertubercular groove of the humerus may be related to high-grade lesions to the long head of the biceps. Rotator cuff injury and its size are risk factors for high-grade injuries to the long head of the biceps tendon.

Resumo Objetivo Identificar a correlação clínica, radiológica, e artroscópica das lesões do tendão da cabeça longa do bíceps e sua influência na dor do paciente quando associada às lesões do manguito rotador. Métodos Entre abril e dezembro de 2013, foram avaliados 50 pacientes, sendo 38 (76%) do sexo feminino e 12 (24%) do sexo masculino, com idade média de 65,1 anos. Os pacientes foram operados pelo Grupo de Ombro e Cotovelo da Disciplina de Medicina Esportiva do Departamento de Ortopedia e Traumatologia da Universidade Federal de São Paulo. Os indivíduos foram submetidos a reparo da lesão do manguito rotador com evidência clínica, radiológica e/ou artroscópica de acometimento do tendão da cabeça longa do bíceps. Resultados Observou-se associação entre dor à palpação do sulco intertubercular do úmero com lesão parcial de alto grau (ruptura parcial acometendo mais de 50% do tendão) na artroscopia (p = 0,003). Encontramos ainda uma associação entre a lesão de alto grau da cabeça longa do bíceps e a lesão do tendão do músculo supraespinal (p < 0,05), sendo que, para cada centímetro de lesão do tendão do músculo supraespinal, o paciente apresenta probabilidade 1,7 maior de ter uma lesão de alto grau da cabeça longa do bíceps. Conclusão A dor na região anterior do ombro à palpação do sulco intertubercular do úmero pode estar relacionada às lesões de alto grau da cabeça longa do bíceps. A lesão do manguito rotador e o seu tamanho são fatores de risco para lesão de alto grau do tendão da cabeça longa do bíceps.

Additional head of biceps brachii: a cadaveric study

Background: The biceps brachii is an important muscle of anterior compartment of arm. It shows frequent anatomic variability due to presence of supernumerary heads. Knowledge of the existence of the third head of biceps brachii is important for surgeons. Keeping this in mind a study was planned to see the incidence of additional head of biceps brachii in sample Indian population and to compare it with other racial groups.Methods: The study was carried out on 30 cadaveric upper limbs. The upper limbs were dissected and studied for the presence of additional head of biceps brachii. The attachment and nerve supply of the additional head was carefully observed, recorded and documented.Results: Out of 30 limbs which were dissected, additional head of biceps brachii was found only in two limbs. In both the cases the additional head was present only on the right side and arose from the anterior surface of humerus, superomedial to the origin of brachialis. The additional head fused with the common bulk of the muscle and was inserted into the radial tuberosity and bicipital aponeurosis. The extra heads of biceps brachii muscle received branches from musculocutaneous nerve.Conclusions: Biceps brachii is one of the commonest muscles showing variations. The additional head is not only of academic importance, but its knowledge also helps clinicians in managing fractures of humerus and nerve entrapment.

Reinsertion of Distal Brachial Biceps Tendon Rupture through Single Incision Using Anchors / Reinserção da ruptura distal do bíceps braquial mediante incisão única com uso de âncoras

Abstract Objective To evaluate 15 patients with ruptured distal biceps tendon submitted to reinsertion via a single, anterior and transverse approach using two anchors. They were submitted to a rehabilitation protocol and, within six months, to an evaluation of the range of motion and strength intensity during flexion and supination of the operated elbow. Methods The data were collected prospectively, and were analyzed through the Mann-Whitney test and the mixed-model test to evaluate the force between the operated and non-operated elbows. Results A total of 80% of the patients were men, 60% were injured on the dominant side, 46% were manual workers, and 73% led sedentary lifestyles. The use of anabolic steroids was reported by two patients. After the treatment, the patients recovered supination strength by 98% and flexion by 94%. According to the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, 73% of the patients presented the score expected of a normal population. Conclusion The single, anterior and transverse approach associated with tendon repair using anchors was esthetically satisfactory, with good strength recovery during flexion and supination, and no occurrence of heterotopic ossification.

Resumo Objetivo Avaliar 15 pacientes com ruptura do tendão distal do bíceps submetidos a reinserção por meio de via única, anterior e transversa no antebraço com o uso de duas âncoras. Os pacientes foram submetidos a um protocolo de reabilitação e, ao término de seis meses, efetuou-se avaliação do arco de movimento do cotovelo operado e da intensidade de força durante a flexão e a supinação. Métodos Os dados foram coletados de maneira prospectiva, e foram analisados pelo teste de Mann-Whitney e pelo teste de modelos mistos para avaliar a força entre os cotovelos operado e não operado. Resultados Um total de 80% dos pacientes eram homens, 60% sofreram lesão do lado dominante, 46% eram trabalhadores braçais, e 73% não praticavam atividades físicas regularmente. O uso de anabolizante foi relatado por dois pacientes. Após o tratamento, os pacientes recuperaram 98% da força de supinação, e 94% da de flexão. De acordo com questionário de Disfunções do Braço, Ombro e Mão (Disabilities of the Arm, Shoulder and Hand, DASH), 73% dos pacientes encontram-se dentro do esperado para uma população normal. Conclusão A via única, anterior e transversa associada ao reparo do tendão com o uso de âncoras apresentou-se esteticamente satisfatória, com boa recuperação da força durante a flexão e a supinação, não ocorrendo casos de ossificação heterotópica ou complicações graves.

Reconstruction with interference screw of ruptured distal biceps brachii tendon at level of insertion into radial tuberosity: a case report

Distal biceps tendon rupture is a relatively rare injury. The incidence of distal biceps rupture is 1.2 cases per 100,000 patients per year, with the average age is 47 years old and the majority is male patient with dominant extremity. A 43 years old male presented with pain of the left elbow and weakness to flex and supinate the forearm following gymnastic activity. He heard pop sound on his left elbow during lifting dumbbell and followed by a sudden pain on his arm and weakness to flex and supinate the elbow. The USG examination were performed and confirmed there was a rupture on the distal biceps tendon at the level of insertion. Durante operation confirmed a complete rupture of distal biceps tendon. A Henry approach incision is performed to expose radial tuberosity, and the ruptured tendon was reconstructed by anchored into the tuberosity of radius with bioabsorbable screw. After closing the incision, patient is immobilized by cast in 60 to 90o elbow flexion and neutral pronosupination. Distal biceps tendon rupture can be successfully repaired by single anterior approach using anatomical anchor on radial tuberosity, so that can avoid posterior approach and associated proximal radioulnar synostosis risk while conserving interosseous membrane.

Third head of the biceps brachii muscle originated from the greater tubercle connecting long and short heads: a case report / Tercera cabeza del músculo bíceps braquial originada en la tubrosidad mayor del húmero conectando las cabezas larga y corta: informe de un caso

Variation in the biceps brachii muscle is extremely frequent and has a clinical significance. During an educational dissection, third head of the biceps brachii muscle was found on the left side in a Korean cadaver. The short and long heads showed normal morphology and course: however, additional head originated from the greater tubercle connected to long head of biceps brachii muscle and crossed the musculocutaneous nerve perpendicularly. And then, it was inserted into short head of the biceps brachii muscle. The author describes this previously novel case report and discusses the clinical implications of such a variant.

La variación en el músculo bíceps braquial es extremadamente frecuente y tiene un significado clínico. Durante una disección educativa, se encontró la tercera cabeza del músculo bíceps braquial en el lado izquierdo de un cadáver coreano. Las cabezas cortas y largas mostraron una morfología y curso normales: sin embargo, la cabeza adicional se originó de la tuberosidad mayor conectado a la cabeza larga del músculo bíceps braquial y cruzaba el nervio musculocutáneo perpendicularmente, insertándose en la cabeza corta del músculo bíceps braquial. El autor describe este informe de un caso novedoso y discute las implicaciones clínicas de tal variante.

The third head of the biceps brachii muscle perforated by the musculocutaneous nerve / La tercera cabeza del músculo bíceps braquial perforada por el nervio musculocutáneo

During an educational dissection, the third head of the biceps brachii muscle was found on the left side in a 63-yearold female Korean cadaver. The short and long heads showed normal morphology, and their courses were as follows: The third head was originated from the middle level of the humerus under the short head and inserted in the conjoined tendon of the long and short heads of the biceps brachii muscle. The musculocutaneous nerve penetrated the third head of the biceps brachii muscle and became the lateral cutaneous nerve of the forearm. The authors describe this novel case and discuss the clinical implications of such a variation.

Durante una disección educativa, la tercera cabeza del músculo bíceps braquial se encontró en el lado izquierdo en un cadáver coreano de 63 años de edad. La cabeza corta y la cabeza larga mostraron una morfología normal, y se presentaron de la siguiente forma: La tercera cabeza se originó en el nivel medio del húmero, inferior a la cabeza corta, y se insertó en el tendón unido de las cabezas larga y corta del músculo bíceps braquial. El nervio musculocutáneo penetró en la tercera cabeza del músculo bíceps braquial para transformarse en el nervio cutáneo lateral del antebrazo. Los autores describen este nuevo caso y discuten las implicaciones clínicas de esta variación.