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- Modified arthroscopic transfer of the long head of the biceps tendon to the conjoint tendon-Chinese Medical Journal 2009;122(6)
- 作者:马勇|发布时间:2010-06-27|浏览量:845次
作者:
MA Yong, CUI Guo-qing, AO Ying-fang, XIAO Jian, YAN Hui, YANG Yu-ping and XIE Xing
The long head of the biceps tendon (LHBT) pathology has been implicated as a common source of shoulder pain. The patients may be more resistant to conservative treatment than those with isolated subacromial impingement.1 Even though, the surgical options of this disease remain controversial. It has been reported that tenotomy and tenodesis of the biceps tendon were usually utilized. However, persistent pain, deformity, and muscle cramping were frequently observed.1-3 Transfer of the LHBT to the conjoint tendon was originally described by Post and Benca in 1982.4 O’Brien et al has performed the transfer under arthroscopy since 2004.1 Eighty percent of their patients reported good results with a minimum 2 years of follow-up.2 However, there was a steep learning curve to become proficient in their technique. We devised a more convenient transfer compared with O’Brien’s technique. Six patients received our modified arthroscopic transfers from May 2006 to May 2007. All of them obtained good results.北京大学第三医院运动医学科马勇
CLINICAL DATA
Patients and their clinical characteristics
There were six patients in this series. Five were men and one was woman. The age of them ranged from 39 to 58 years (mean age 45 years old). Only one had a traumatic rupture of the LHBT with typical clinical manifestations of a Popeye sign (Fig. 1) and a regional pain. The other five were diagnosed subacromial impingement including refractory biceps tendonitis (2) or spontaneous rupture of LHBT (3). The predominant symptom on initial presentation was shoulder pain. Additional manifestations included tenderness on the intertubercular groove, positive Speed test and weakness. The five patients had received rest, ice, oral nonsteroidal anti-inflammatory drugs, physical therapy and local steroid injections. However, the symptoms failed to be relieved for at least 3 months under the conservative therapies. X-ray examinations and MRI scans of the involved shoulder joints were routinely carried out to all patients before surgery.
Operative procedure
The patient was placed in the beach chair position under general anesthesia. Arterial blood pressure was monitored as a routine and the systolic was kept at 90~95 mmHg. So, the bleeding could be controlled and a good visual field would be obtained. The involved upper extremity was kept free to make sure that the shoulder joint have all ranged passive motion. Bony landmarks, acromion, coracoid and acromioclavicular joint, were routinely outlined preoperatively. A standard posterior portal was established and the diagnostic arthroscopy was performed. The LHBT, especially the entry to the bicipital groove, and its anchor to the superior labrum were inspected. Fraying of the base of the tendon and partial tears could be seen. Once the debridement was done, only less than 50% thick tendon of the LHBT was left. Then, the LHBT was released. No biceps tendon can be found in the glenohumeral joint in the ruptured cases. The remaining stump was debrided using a mechanical shaver, and any other concomitant pathology was dealt with at that time. A subacromial decompression was performed using a radiofrequency probe and a burr when clinically indicated by impingement signs and symptoms. The involved rotator cuff was debrided or sutured.
The camera was placed in the anterolateral portal. The arm was kept in flexion position about 60°. The anterosuperior portal would be used for working during the initial exposure. With the aid of a shaver and a radiofrequency device, the subdeltoid bursa was resected. Along with coracoacromial ligament, the coracoid and the conjoint tendon could be identified. An anteroinferior portal was then made. At the lateral side of the conjoint tendon, the space can be spread down to the superior border of pectoralis tendon. The bicipital sleeve was then opened and the released LHBT was exposed. The LHBT could be tagged with PDS traction stitches. Then the Neviaser portal, a key portal, was made at approximately 2 to 3 mm posterior to the acromioclavicular joint, in the “soft spot” bordered by the posterior margin of the clavicle, medial margin of the acromion, and the scapular spine. The traction PDS stitches were drawn out from the Neviaser portal (Fig. 2).
In the ruptured cases, overgrowth scar could be seen surround the bicipital groove. The LHBT could not be released easily under arthroscopy. An additional 2-cm incision was made just below the inferior margin of the pectoralis major tendon. The LHBT was removed extracorporally through the incision and tagged with 2-ethibond Thompson traction stitches. The tendon was then placed back into the subdeltoid space, and the traction sutures were also pulled out of the Neviaser portal.
The LHBT was tensioned in line with the conjoint tendon by pulling on the tagging sutures. At the same time, the elbow was flexed to 90°. A suture punch was then passed through anterosuperior portal with PDS stitches to make side-by-side suture of the LHBT and conjoint tendon. Then the PDS stitches were replaced by 2-ethibond Thompson stitches. Three looped sutures were made in total (Fig. 3). There were two important techniques. One was to place the tendon anteriorly along the lateral aspect of the conjoint tendon to avoid coracoid impingement. The other was to make the sutured part of the conjoint tendon be within 2.5 cm from coracoid.
Postoperative management
After surgery, patients were placed in a sling full time for the first 3 weeks with the elbow being flexed to 90°. Passive shoulder motion was allowed in the sling immediately postoperatively. Patients were encouraged to come out of the sling for active and active-assisted elbow range of motion 3 weeks later. In the meanwhile, they were not allowed to lift anything heavier than a pen, knife, fork, or spoon. They were allowed complete activities of daily living at 4 weeks, full throwing and swimming as tolerated at 3 months, and unrestricted activity including lifting at 4 to 5 months.
Results
The operations took 30 minutes averagely (from 25 to 80 minutes). The mean duration of follow-up was 8.4 months (range, from 3 to 15 months). Three months later, the shoulder pain disappeared, the Speed and Yergason tests were negative and we found no Popeye sign or side by side difference in elbow-flexed strength. No complications of blood vessel, nerve, tendon injury or restricted ROM of shoulder and elbow occurred. The satisfaction rate ranged from 80% to 95%.
DISCUSSION
Surgical treatment of the LHBT
The LHBT has been considered as a common source of shoulder pain and the surgical treatment of its lesions is well accepted1-3. The LHBT transfer or tenodesis was recommended for irreversible structural changes in the tendon such as significant atrophy or hypertrophy, partial tearing greater than 25% of the width, any luxation from the groove and certain disorders of the origin. 2,3,6 The suture was preferred for the younger patient (less than 60 years). An acceptable alternative in the older patient was tenotomy. Our cases were consistent with these indications and the partial tears were greater than 50% of the width. There was no absolute contraindication to tenotomy or tenodesis of the LHBT. Some investigators have suggested that the tendon played a critical role in the shoulder stability. They said some clinical entities related to shoulder joint instability must be considered. Those included rotator cuff rupture, capsular injury and glenoid labrum tear. However, most of those entities can be resolved under arthroscopy now. There were wide shifts in the surgical treatment of the LHBT including tenotomy, tenodesis and transfer. Techniques for tenodesis included variety of open or arthroscopic techniques using bony fixation of the tendon to the proximal humerus.6-12 However, high levels of postoperative pain at the tenodesis site were reported (6-40%).7-12 There have been reports of pain relief in patients who have spontaneous ruptures of the LHBT. 6,13,14 This led some surgeons to perform simple tenotomies. Kelly6 reported on 40 patients who had a tenotomy of the LHBT. There was a relatively high incidence of fatigue discomfort symptom and Popeye sign, particularly in young patients. A kind of transfer technique was first reported by Gilcreest15, who describe suturing the stump of the tendon to the coracoid process after tendon rupture, in 1936. Transfer of the LHBT to the conjoint tendon has more advantages over other techniques. First, tendons can heal more rapid than tendon to bone. Second, 2.5 cm suture provides enough area for the healing. Third, it closely reproduces the native axis of pull of the biceps muscle and allows the long head and short head to share load. At last, it can avoid the complications such as weakness, cosmetic deformity or pain at the tenodesis site. In the present study, we obtained satisfactory results, and all the patients reported no pain in the bicipital groove at rest or in activity. No obvious strength difference was found between the involved and contralateral biceps muscle.
Modified arthroscopic transfer techniques
O’Brien placed the patient in a “modified beach chair position”.1,2 They partially immobilized the shoulder joint motion to let the humeral head fall posteriorly via gravity and open the subdeltoid space. The traction of the LHBT was pulled through anteroinferior portal and they added a new portal, the “pectoralis portal”.2 We improved the procedure to make a shorter learning curve. First, the patient was placed in the beach chair position, the most familiar position. The assistant could draw the upper extremity in all range to open the visual field. Second, when the LHBT was pulled through anteroinferior portal, it would be far away from the conjoint tendon and it need a challenging suture. We held the transfer through the Neviaser portal. This technique put the LHBT more close to the conjoint tendon, which made an easier side-by-side suture. Furthermore, the anteroinferior portal is an important working portal. Third, the anteroinferior portal was liberated, and we avoided the strange “pectoralis portal”. In the meanwhile, it was unnecessary to change the working portal and the viewing portal as frequently as the techniques described by O’Brien. Therefore, the operative time was reduced.
There are some keys which we must take into account. Firstly, it is critical to transfer the LHBT to the anterolateral surface of the conjoint tendon. This will avoid coracoid impingement as well as protect the musculocutaneous nerve from injury. We have made it sure by using the Neviaser portal. The suturing space within 2.5 cm from coracoid also protects the anterior humeral circumflex artery and musculocutaneous nerve. Secondly, in the LHBT ruptured cases, the tendon can be easily found through an incision made just below the inferior margin of the pectoralis major tendon. Finally, the elbow must be flexed to 90 degrees and LHBT must be tensioned when we make the sutures. The postoperative biceps strength just depends on the final manipulations.
In summary, the modified arthroscopic transfer of the LHBT to the conjoint tendon has the advantages of mini-invasive, safety, short learning curve and good results. We would like to emphasize that our operative time for the transfer has been markedly reduced by using of the Neviaser portal.
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