Arthroscopic Treatment of Irreparable Rotator Cuff Tears using Fascia Lata Autografts: Preliminary Results

Acta of Shoulder and Elbow Surgery | Volume 2 | Issue 1 | Jan-June 2017 | Page 3-6 | Niso Eduardo Balsini, Olinto Lago Junior

Authors: Niso Eduardo Balsini [1], Olinto Lago Junior [1]

[1] NAEON-Santa Catarina Hospital.
[2] IFOR Hospital.

Address of Correspondence
Dr. Jose Carlos Garcia Jr., MD, MSc, PhD
NÆON-Hospital Santa Catarina-SP-Brazil


Better knowledge of lesion patterns together with advances in surgical devices and techniques have allowed the arthroscopic repair of large rotator cuff tears. However, there are still challenging situations such as chronic retracted degenerated cuff tears whose results of primary anatomic repair attempts are uncertain and unsatisfactory. Many of these tears are considered irreparable.
Recently, extracellular matrix scaffolds and tendon grafts have presented good results in the management of these “irreparable” tears.
In order to evaluate preliminary results of fascia lata autograft for treating complex irreparable rotator tears, five patients were operated and folowed by a mean of twelve months. Outcomes were measured using the UCLA, Visual Analogical Score for pain (VAS) and Constant scores. Results demonstrated fascia lata technique is useful to treat irreparable rotator cuff tears rendering significant functional improvement for patients.
Keywords: Arthroscopy, fascia lata, autologous tendon graft, massive rotator cuff tears.


Rotator cuff tear is an important cause of shoulder pain and disfunction. It affects about 40% of the United States population over 60 years-old requiring 30,000 to 75,000 rotator cuff repairs annually [1,2].
The rotator cuff tear is an important cause of shoulder pain and functional limitation. It affects approximately 40% of patients over 60 years old in the United States and between 30,000 to 75,000 rotator cuff repairs are performed annually [1,2].
Better knowledge of lesion patterns together with advances in surgical devices and techniques have allowed an overall tendon healing of 80% for smaller tears. On the other hand, large and massive tears are still a challenge for orthopedic surgeons. Their healing rates are lower than 30% [3].
To reduce failure of massive tears repairs, adjuvant grafts like synthetic dermal grafts, extracellular matrix scaffolds and fascia lata autografts have been proposed [4,5].
The purpose of this study is to evaluate preliminary results of arthroscopic treatment of massive irreparable rotator cuff tears using an autologous fascia lata graft to fill the cuff-to-bone gap.


Inclusion and Exclusion Criterea
Patients whose MRI presented supraspinatus and/or infraspinatus tears greater than 3 cm in medial-lateral or antero-posterior diameters and muscle fat degeneration stages III or IV of Goutallier-Fuchs [6] classification were considered potential irreparable tears. They were advised pre-operativelly about the possibility of requiring a fascia lata autograft in case a tension-free tendon-to-bone reattachment cannot be achieved using conventional cuff repair techniques. Thus, at the time of surgery the ipsilateral thigh was also prepared with asepsis and antisepsis for this purpose.
Inclusion criteria were: (1) Patte’s medial-to-lateral retraction grade 3 [7]; (2) Goutallier-Fuchs supraspinatus and/or infraspinatus fat degeneration stages III or IV; (3) Teres Minor intact (negative Horner Test); and (4) intraoperative gap preventing cuff-to-bone attachment.
Exclusion criteria: (1) Goutallier-Fuchs stages I and II; (2) Neurologic impairment; (3) Irreparable subscapularis tears; (4) Rotator cuff arthropathy greater than stage 2 of Seebauer classification [8].

Patient evaluation
All patients were evaluated pre- and post-operativelly using visual analisys score (VAS), UCLA and Constant scores one month before and six months after the surgery. Active range of movement (ROM) and painless ROM were evaluated for anterior elevation, external rotation and internal rotation comparing to contralateral side. A digital dynamometer was used to measure shoulder elevation strengh in orthostatic position with arm positioned at 90º of abduction in the scapular plane, elbow extended and forearm pronated. Measurement was performed 3 times and average was recorded. Data related to Constant score compared both sides and the difference of values was defined as excellent (<11); good (11 to 20); fair (21 to 30); and poor (>30 points).

MRI evaluation
The degree of fatty infiltration of supraspinatus, infraspinatus and subscapularis was graded analysing sagittal MRI cuts using the Goutallier classification adapted for MRI by Fuchs. Muscle degeneration was graded using the most lateral T1 image in which spine of scapula was seen in contact with its body (scapular Y view). According to Goutallier-Fuchs [6,9], a five-stage classification was used: no fat infiltration (stage 0); occasional lines of fat between muscle fibers (stage 1); significant amount of fat, but fat-muscle ratio lower than 50% (stage 2); fat-muscle ratio of 50% (stage 3); fat-muscle ratio higher than 50% (stage 4).
Cuff retraction was graded according to Patte classification: retraction at the level of greater tuberosity (grade 1); retraction at the level of humeral head (grade2); retraction at glenoid level (grade 3).
Cuff and graft healing and re-rupture were evaluated by MRI according to criterea well stablished in literature [10, 11, 12]. Complete tears in repaired cuffs were diagnosed when presence of high-intensity signal or tendon-to-bone gap on two or more consecutive T2-weighted cuts. Grafts were evaluated based on their appearance compared to rotator cuff remains at tendon-graft interface and at humeral head footprint. Intact grafts showed absence of high intensity signal at areas of native rotator cuff, tendon-graft and humeral head-graft interfaces. Not-intact grafts showed high intensity signal that these interfaces.

Operative Technique and Fascia Lata autograft usage decision during surgery
With patient in lateral decubitus under general anesthesia and traction on arm, camera was introduced on posterior portal to evaluate the glenohumeral joint. At this stage, subscapularis tendon was evaluated and repaired if necessary. Also, long head of biceps was evaluated for instability or degeneration and if positive, a tenotomy or tenodesis were performed.
After that, the scope was taken to subacromial space and bursectomy was performed. Rotator cuff tear was identified and classified according to shape (L, inverted L, U or C), length and retraction (width) using a calibrated ‘probe’. Tears greater than 5 cm in length or width were classified as massive. If between 3 and 5 cm, they are graded as large [6].
The cuff repair was always tried aiming a tension-free tendon-to-bone attachment. Capsular release, rotator interval sliding and tendon-to-tendon stitches were used when necessary. If even after that, there was still a gap between the tendon and the greater tuberosity, the tear was considered irreparable and fascia lata autograft was used to fill in the gap.

Fascia lata autograft removal from ipsilateral thigh
The fascia lata autograft was removed from ipsilateral thigh using a lateral incision 10 cm above knee joint line. (Figure 1). To avoid insufficient graft tissue, we always oversized 5 mm in addition to gap length and width. Finally, edges of graft were tied with a continuous PDS 5.0 suture (figure 2).

Graft placement and tendon-to-graft repair
Usually five portal were used to tendon-to-graft suture: posterior, anterolateral, lateral, lateral accessory and Neviaser. If necessary other portals may be used to reach a better angle for anchor insertion, sutures placement or adhesion releases.
Cannulas were introduced on posterior, anterolateral and lateral portals. Two No.2 Ethibond threads were placed at supraspinatus edge through Neviaser portal. One thread at infraspinatus through posterior portal. Moreover, another thread at rotator interval through anterolateral portal. All four threads were taken to the lateral cannula to be stitched to the fascia lata graft. Afterwards, each thread was repositioned to its respective portal.
Introducting the graft onto subacromial space was always a delicate step, which requires progressive traction to threads and concomitant assistance to pass the graft through the lateral cannula avoiding folding or twist. In this way, the graft was strained open in the subacromial space with the use of a probe and knots were performed is the following sequence (figure 4): first two knots on the supraspinatus; then the one on infraspinatus; and finally the rotator interval knot.
At last, two or three suture anchors were placed on greater tuberosity to attach the graft to bone with ‘Revo” simple knots.

Post-operative care
All patients were immobilized with a sling for 60 days. At fourth month postoperatively, a MRI was done to evaluate healing and positioning of the graft (figure 5).


From January to June 2016, eight patients received the fascia lata grafting for irreparable rotator cuff tears. Three patients were male and two females. They were followed up for an average of nine months post-operatively (6 to 18 months). Average age was 67 year-old (49 to 80 range). According to Goutallier-Fuchs, five patients were classified as stage III and three stage IV. All patients were Patte’s grade III. Four cases were failured repairs and four were primary surgeries. Three cases required subscapularis repair and biceps tenotomy was performed in four cases and one biceps tenodesis was performed (Table 1).

Functional scores
VAS pre-operatively was 7.87±0.55 and decresed to 1.25±0,37 points post-operatively (P<0.001) (Table 2) . The Constant score raised from 34.38±2.73 to 85.00±1.73 (P<0.001) (Table 3). In addition, UCLA score improved from 10.50±1.82 to 32±0.48 (P<0.001) (Table 4).
All curves passed in the DAgostino & Person normality test. Statistical analysis was performed by using the Student’s T test. Scores improvement was as follows in Table 5.

MRI evaluation
All eight cases repeated MRI after 16 weeks of surgery. Seven patients presented continuity of tendon fibers-to-graft and graft-to-bone suggesting complete graft healing. One case presented a hypersignal on graft-to-bone interface at one coronal slice, which suggests incomplete integration of graft to bone. However, other slices had normal graft-tendon interface signals and patient had satisfactory functional scores. So, seven cases were considered to have complete healing and one partial healing.

There was one case of hematoma at the donor site for fascia lata graft that resolved spontaneously. Another patient had a frozen shoulder that evolved to complete ROM afetr six serial suprascapular nerve blocks.


A reason for difficult treatment of massive rotator cuff tears is that pathogenesis of these lesions has not been fully clarified yet. Besides, rotator cuff has limited healing capacity at its humeral insertion. To overcome these limitations, new techniques have been proposed, like improving biomechanics with double-row repairs, biological enhancements using growth factors, cytokines, platelet-rich plasma (PRP), tendon grafting, extracellular scaffolds, gene therapy and tissue engineering on mesechymal cells 1.
Nowadays, extracellular matrix derivative scaffolds, polyurethane-urea and poly-L-lactic (PLLA) are commercially available and FDA approved to enhance rotator cuff repairs in humans. Their aim is to serve as a patch attached to the cuff supporting cell ingrowth over it [1]. Several studies have demonstrated pain reduction, improved daily live activities, satisfaction and cuff stregth increase with these scaffolds compared to pre-operative conditions [1,2].
Other option available is the human dermal matrix allograft for tendon augmentation. The allograft is processed and become acellular, which reduces immunogenic response, while extracellular collagen matrix remains intact and provide strength and support to tissue ingrowth [2].
The muscle fascia has similar structural and biochemical properties of a healthy tendon, but it has poor suture retention properties (10N), which limits its utility as a scaffold for rotator cuff repairs [1]. An alternative solution is to reinforce fascia with a PLLA polymer. Studies have showed that this technique may improve suture retention properties and decrease cyclic retraction gaps, turning it comparable to a human tendon. Soon, there will be reinforced fascias that will provide the necessary mechanical strength to enhance rotator cuff repairs, minimizing retractions and reducing rapair failures [1].
Fascia lata autografts are consolidated techniques widely used in many areas of medicine like plastic surgery, neurosurgey, urology, orthopedics and ophthalmology. Complex cases head trauma with extensive loss of the scalp have shown good results using fascia lata grafts [13]. Barbosa et al used the fascia lata tensor muscle for operative wound complications in patients with genital neoplasia and severe inguinal defects, reporting that the graft is an important tool for reconstructing the inguinal ligament [14]. Sebastiá et al showed that fascia lata graft reduces incidence of complications in reconstructions of anophthalmic cavity with inclusion of implants coated with this graft [15]. Bayat et al used a fascia lata graft in an alpinist to reconstruct bilateral chronic retracted distal biceps rupture. Results were satisfactory regarding the supination and flexion strength of the elbow16.
Mori et al [17]compared 24 patients who underwent partial repair for massive irreparable rotator cuff tears to 24 patients with similar tears that underwent fascia lata graft to fill the gap. The recurrence rate in the partial repair group was 41.7% while in the fascia late group it was 8.1%. The technique described in this article differs from Mori’s technique in graft removal and in the preparation of the graft. Mori removes the graft from proximal thigh, close to the greater trochanter, while we remove fascia lata at a distal thigh site close to the knee. In addition, we have created a double graft by removing a larger graft size and folding it by half, while Mori uses a single leaf graft.
McCarron et al [5] evaluated the biomechanical properties of the fascia lata graft on 18 cadavers with 5 cm irreparable rotator cuff tear created by disinsertion of supraspinatus from the proximal humerus. In half of cases, the cuff was reattached using suture anchors only, while the other half received suture anchors and fascia lata grafts. All shoulders were subjected to a thousand cycles of 180N loading. Results showed the group with fascia lata reinforcement presented gaps along suture line 40% smaller than the group without it, suggesting that fascia lata minimizes tendon retraction and thereby decreases incidence of cuff repair failure [5].
Baker et al [4] in an amimal study compared biomechanical properties of eleven dogs submitted to surgery in both shoulders. In one group, only partial sutures were done and in the other fascia, lata reinforcement was performed. Results showed a significant increase in the loading force of tendon that received the fascia lata graft, suggesting that this technique might bring benefits to humans.
Based on these reports, we decided to use fascia lata autograft to repair complex rotator cuff tears due to small complication rates, low morbidity at donor site, feasible technique and lower surgical cost when compared to synthetic grafts. In addition, our technique follows the biological concept of graft use for orthopedic lesions.
As massive irreparable rotator cuff tears are relatively uncommon lesions, it is difficult to obtain large numbers of patients in order to produce a prospective randomized surgical Trial. So future comparative papers are necessary to prove effectiveness of this procedure. However, it is still a good and cheap option for dealing with chronic irreparable rotator cuff tears in patients younger than 70 years-old.
For the future, we understand there is a great difference between repair and tissue regeneration quality. Facing this undesired dichotomy, we intend to direct our future research to study biological evolution of the fascia lata graft to tendon healing.

Interest conflicts

The authors declare no conflict of interest.


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How to Cite this article: Balsini N E, Junior O L. Arthroscopic Treatment of Irreparable Rotator Cuff Tears using Fascia Lata Autografts: Preliminary Results. Acta of Shoulder and Elbow Surgery Jan – June 2017;2(1):3-6.


Niso Eduardo Balsini

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The Diagnosis and Management of Superior Labral (SLAP) Tears of the Shoulder: A Review Article

Acta of Shoulder and Elbow Surgery | Volume 2| Issue 1 | Jan-Jun 2017 | Page 15-21| Bijayendra Singh, N Bakti

Authors: Bijayendra Singh [1], N Bakti [1]

[1]Medway NHS Foundation Trust, Visiting Professor Canterbury Christchurch University.

Address of Correspondence
Prof. Bijayendra Singh,
Consultant Orthopaedic Surgeon,
Medway NHS Foundation Trust, Visiting Professor Canterbury Christchurch University, Medway, KENT


The labrum helps deepen the glenoid and serves as an attachment of the long head of biceps. Superior Labrum antero posterior (SLAP) tears are common in the overhead throwing athlete and is a common cause of shoulder pain in the younger population. Often its due to repetitive throwing action or may present after a single acute injury. The diagnosis can be challenging and hence a careful history and examination followed by investigation is key to clinch the diagnosis. The normal variants of the capsulo – labral complex can make the diagnosis difficult. A thorough understanding of the condition is hence essential. This article reviews the relevant anatomy, clinical diagnosis, investigations and management of the condition.
Keywords: Superior Labrum Antero Posterior, SLAP, Arthroscopy, Stabilization, Tenodesis.


Andrews et al first described superior labral anterior-posterior lesions (SLAP) of the shoulder in 1985 amongst overhead-throwing athletes [1]. Recent published studies have reported an incidence between 6% and 20% and are not exclusive to these athletes [2]. Pathogenesis can be related to trauma or part of a degenerative process. For the treating Orthopaedic surgeon, SLAP pathologies can be a challenging problem to manage due to ambiguity in clinical diagnosis, variation in normal labral anatomy and controversies in treatment.

Role and function
The labrum helps deepen the anatomically shallow glenoid, which in turn helps confer additional passive stability to the glenohumeral joint [3]. The superior aspect of the labrum also serves as points of attachment of the tendon for the long head of biceps, the superior and middle glenohumeral ligament (MGHL) and the posterior-superior aspect of the capsule, they have an important role in stabilizing the shoulder especially in the first half of shoulder elevation [4, 5].

Histologically, the superior labrum is a triangular structure and is composed of fibrous and fibrocartilaginous tissue [3, 6]. Vascular supply to this region of the labrum is from joint capsule via the branches of the suprascapular artery, the circumflex scapular branch of the subscapular artery and the posterior humeral circumflex artery [6].
Literature describes significant variability in the anatomy of the superior aspect of the glenoid labrum and the attachment of the long head of biceps, which can cloud the management of a SLAP pathology [3]. Williams et al retrospectively reviewed 200 consecutive shoulder arthroscopies to find a 12% incidence of a sublabral foramen [7]. When this variation was present, 75% of the patients had a ‘cord-like’ appearance of the MGHL that attaches directly to the labrum. The group also noted a rare variation, known as the Buford complex, which occurred in 1.5% of the arthroscopies they reviewed. This is described as a cord like MGHL with an anterior superior glenoid that is devoid of a labrum. Subsequent published studies have further confirmed the incidence rates of these normal anatomical variations [ 8, 9].
In addition, the labrum can appear meniscoid as it drapes over the superior glenoid articular cartilage, which may give an appearance of labral detachment [10]. The surgeon must be aware of these, as reattachment or repair of these normal variations can lead to a significant loss of range of motion of the shoulder [11].

SLAP lesions were first noted as a repetitive injury in overhead-throwing athletes [1]. Increased external rotation of the shoulder at the cocking phase of a throw displaces the labrum and biceps tendon medially and is thought to increase torsional force at the biceps anchor. This results in a phenomenon known as ‘peel-back’ injury to the labrum [12]. These athletes also increase the forces at the superior labrum by adopting a reduced internal rotation motion while in the abducted position of a throw [12, 13]
SLAP tears can also occur due to forceful traction to the shoulder, direct compression injuries or fall on an abducted and externally rotated arm. The position of the shoulder at the point of impact loading is thought to be key and studies have shown SLAP tears are more likely to occur when the shoulder is forward flexed rather than extended [14]

In 1990, Snyder et al described four types of SLAP lesions based retrospective review of 700 shoulder arthroscopies [15]. Over the last 30 years, this classification has been expanded to include six more types but Synder’s original classification is still the most recognized and widely used.
In Snyder’s paper, he described Type I SLAP lesions as a superior labral fraying with localized degeneration. The superior labrum and the biceps anchor remain intact and patients are commonly middle-aged and clinically asymptomatic.
Type II lesions occur when there is detachment of the labrum and the biceps anchor from its attachment to the glenoid. This type of SLAP pathology is the most clinically significant variant.
Type III lesion is a bucket handle tear superior labrum with the biceps anchor still intact. This phenomenon is very similar to a bucket handle injury of the meniscus in the knee joint and if significantly unstable, it can displace into the glenohumeral joint to cause mechanical symptoms.
Type IV lesions differ form Type III lesions by having split in the biceps tendon itself and this split is included in the bucket handle component of the SLAP tear.

Clinical diagnosis
Making a clinical diagnosis of a SLAP lesion can be challenging for a myriad of reasons. Patients’ history of preceding events can be variable and examination is often ambiguous and frequently reveals a variety of other co-existing pathologies.

Depending of the specific pathogenesis of the SLAP tear, symptoms can arise insidiously or acutely. Overhead throwing athletes are more likely to present with an insidious history due to the progressive nature of the tear and may complain of reduced throwing velocity and overhead movement. Acute trauma causing a SLAP lesion can be due to a traction injury can be due to unexpected weight shift of a heavy object or a compression injury from a fall on an outstretched limb.
The most common presenting complain in patients with a SLAP pathology is pain [16]. The location of pain can either be felt deep in the shoulder joint or a discomfort radiating to the anterior aspect of the shoulder. The nature of the pain can either be sharp or a dull ache that is often exacerbated by activities of pushing, heavy lifting or overhead actions. For patients with a Type III or IV SLAP pathology, they may complain of mechanical symptoms including sensation of giving way especially when performing overhead activities.
Patient may also complain of weakness to the affected limb. Ganglion cyst formation secondary to a chronic SLAP lesion can cause compression of the suprascapular nerve to result in this symptom.

Clinical examination of patients with suspected SLAP pathology can be unequivocal and confusing as the numerous provocative tests to elicit SLAP lesions lack sensitivity or specificity. Patients also often present with co-existing shoulder pathology to further cloud the clinical picture. One study found 88% of patients with SLAP lesions found at arthroscopy had co-existing shoulder pathology ranging from subacromial impingement, rotator cuff pathology acromioclavicular joint arthritis [8].

When examining a patient with a possible SLAP lesion, pay particular attention to the symmetry of muscle around the shoulder girdle. Wasting of the supraspinatus and infraspinatus muscle may indicate the presence of a glenoid cyst impinging on the suprascapular nerve. In these patients, the active range of motions of the glenohumeral joints often remains normal but pain may be elicited in the position of internal impingement (external rotation of the abducted and externally rotated shoulder) [11]. Stability and apprehension tests of the joint should be tested but significant instability of the joint is rare in SLAP pathologies [16].
Table 1 shows the various tests used to clinically elicit a SLAP lesion. Of these, the O’Brien test is probably the most commonly utilized [17]. To perform this test, the shoulder is position at 90° of flexion, 15° of adduction, full internal rotation and pronation of the forearm. At this point, the patient is asked to flex against resistance. A positive test is declared if patient experiences a deep or anterior shoulder pain. Symptoms should not be reproduced with the shoulder in similar position but in external rotation. Due to the poor reproducibility, sensitivity and specificity the various special tests available, Arnander & Tennant suggested the combination of Kim’s biceps load test II and the O’Brien’s test gave the best likelihood of a positive result in identifying an isolated SLAP lesion [18].

As a baseline, standard plain radiographs (anteroposterior view of shoulder, axillary and scapular ‘Y’ view) of the affected shoulder should be attained. Although this will not help with the diagnosis of SLAP pathology, this practice might highlight any co-existing pathology that will help in formulating a surgical management plan.
Magnetic resonance imaging (MRI) is the gold standard for imaging labral pathologies. When compared to arthroscopy, MRI is thought to have a sensitivity of 90%, specificity of 89.5% and accuracy of 98% [25]. Although there have been debates in the past, several studies have shown that introducing intra-articular contrast into the shoulder can help increase diagnostic sensitivity [26-28]. Despite this, and taking into consideration anatomical variations, interpretation of the MRI images can remain difficult. Identifying SLAP lesions on MRI scan is best done from the coronal oblique sequences and positioning the shoulder in abduction and external rotation is thought to further help with diagnosis.11 Applying axial traction to the arm has also been suggested as a possible technique to increase contrast dissipation into the intra-articular space and hence improve sensitivity [29].

Arthroscopy remains the gold standard in diagnosing SLAP lesions [26, 28, 30]. Direct visualization and gentle probing of the labral-biceps complex often helps identify the lesion. Despite this, arthroscopic findings can be difficult to interpret and knowledge of patients’ presenting history, examination findings, imaging results can help the clinician determine if the visualized labrum represents a pathological process. Awareness of the possible anatomical variations to the superior labrum will also prevent inadvertent repair of an otherwise normal biceps-labral complex.
Several authors have suggested dynamic testing the biceps attachment to the labrum can assist diagnosis by making subtle pathologies more obvious. This is achieved by placing the arm in abduction and external rotation which applies tension to the biceps and can cause the labrum to “peel-away” from the glenoid [12, 31]. Other signs of a pathological labrum-biceps complex include signs of reactive synovitis under the labrum, excessive sublabral recess beyond the edge of the glenoid cartilage and hypermobility of more than 5mm on biceps manipulation [32].

Treatment options
Non operative
Conservative treatment of SLAP pathology revolves mainly around physiotherapy, non-steroidal medications and steroid injections into the shoulder. Although there are no published studies on conservative management of SLAP lesions, authors have experienced poor long-term outcomes following conservative management. Patients are rarely satisfied with their function and ends up requiring surgical intervention an average of one or two years following initial presentation [33].

Surgical Treatment
The role of surgical treatment of SLAP tears is shrouded in controversy. The lack of clear guidelines and randomized control studies further compounds this issue. It is critical to note that not all SLAP lesions identified intra-operatively require repair. Meticulous patient selection taking into consideration patient age, levels of activity and co-existing shoulder pathology should guide the treating surgeon which is the best way to surgically treat a SLAP lesion.

Isolated SLAP Lesions
Type I
This subtype of SLAP lesions is often an incidental finding at arthroscopy as it is usually subclinical in terms of its symptoms. Thought to be secondary to degeneration, it is not usually picked up during MRI imaging and when encountered intraoperatively, it can be left alone. If significantly frayed, it is recommended that the lesion is debrided back to healthy labral tissue [30, 34-36]. Care should be taken to find other co-existing pathology such as subacromial impingement or rotator cuff pathology as a cause of symptoms.

Type II
This is the most common and clinically important subtype of SLAP lesions. It should be treated if patients’ symptoms, clinical examination is suggestive of SLAP pathology and arthroscopic examination of the rest of the shoulder does not reveal any other co-existing shoulder pathology. Managing these isolated lesions can be achieved via various techniques and is again a source of much controversy.
Suture anchors are the most common method of repairing SLAP lesions with more predictable and favorable outcomes when compared to biodegradable tacks [31, 35, 36]. Patients from this treatment group report at least 94% good to excellent results post-operatively and about 74% of patients returned to their pre-injury sporting activities [8, 37] The ideal configuration in terms of the number of anchors and suturing technique; simple, dual simple or horizontal mattress, is again a subject of heated debate. Various studies have been published to support the use of each argument with good outcomes [35, 36, 38]. A prospective study by Bedi et al found similar clinical outcomes in patients independent of the number of suture anchors used for repairing of the SLAP lesion [39].
Despite several of these studies showing good outcomes with primary repair, Denard, in his study, noticed a trend of poor outcomes with increasing age [40]. Provencher et al carried out a large prospective study and agreed with Denard’s findings and highlighted an increased rate of failure of SLAP repairs in patients above the age of 36 [41]. Boileau and his team were first to study the differences in outcome between primary repairs versus biceps tenodesis for SLAP injuries. His team found that 60% of patients who had a repair were dissatisfied or disappointed with their outcomes while 87% of patients in the tenodesis group were satisfied with their outcome with higher rates of return to sports [42]. He also went on to report 40% of patients from the repair cohort required revision surgery due to persistent pain and inability to participate in sports.
Findings of this study were replicated in several other studies and based on these recent evidence, a significant shift has taken place in the management of this subtype of SLAP lesions [10, 43]. It is now recommended that in patients with a isolated type II SLAP lesion, aged above 36 years old, low sporting demand and poor tissue repair quality, a biceps tenodesis is a viable surgical option. This can be performed either arthroscopically or via a mini-open technique. The biceps tendon tenotomised, doubled on a suture and pulled into a humeral socket drilled at the proximal aspect of the bicipital groove. It is fixed in placed using a biodegradable interference screw. These patients had functional outcomes comparable to younger patients with primary repair of their lesions [10].
However, if the patient is under 36 years-old, active athlete with good tissue quality, the recommendation is to still perform a repair of the lesion using suture anchors [42, 44]. This option aims to restore normal anatomy and is most likely influenced by several studies suggesting a key role of the labral-biceps complex in maintaining glenohumeral stabilization [45, 46]. In the event of non-resolution of symptoms or poor overhead performance, biceps tenodesis can still be performed as a salvage procedure with good and predictable outcomes.

Type III
Management of this subtype requires resection of the unstable bucket-handle lesion. It is of upmost importance that the MGHL is not destabilized during the resection process as damage can cause significant anterior instability of the joint [34, 38, 39, 47]

Type IV
Management of Type IV lesions is determined by the extent of biceps tendon involvement and patients’ age. When less than 30% of the biceps tendon is involved, both the labrum and the pathological biceps tendon is debrided and resected. If more than 30% of the biceps is involved, in a young patient, a biceps tenodesis and labral repair is carried out. However, in an older patient or if the labral tissue quality is poor, then a labral debridement is performed with either biceps tenotomy or tenodesis [16].

Type V to X
These subtypes of SLAP injuries often represent a more significant labral injury and are often associated with shoulder instability [11]. Treatment should not only address the labral-biceps complex but also the other parts of the labrum and the MGHL injury.
Slap with co-existing pathologies
Eighty-eight percent of patients with SLAP lesions diagnosed during arthroscopy have co-existing pathology [8]. In view of this, it is recommended to have a clear idea on how to manage these patients based on latest evidence.
SLAP tear with rotator cuff pathology
In patients with these pathologies, it is important to clinically determine which pathology is causing the clinical picture. If both structures are thought to be the generator of symptoms, surgical repair of both can be done at the same sitting with good outcomes [48, 49]. This treatment option is thought to help improve range of motion and patient satisfaction. However, another study looked at patients above the age of 50 with similar dual pathology and found that in this subgroup of patients, managing their pathology with a rotator cuff repair and a biceps tenotomy yielded a significantly better outcome compared to a SLAP and rotator cuff repair [50].

Subacromial Impingement
It is recommended that patients with symptoms of clinical signs of impingement in the shoulder have arthroscopic subacromial decompression during surgery for a SLAP repair. Coleman et al looked at this particular co-existing pathology in his study and concluded that although functional outcome measures were similar in both groups, patients who had an acromioplasty in the same sitting were more satisfied with their surgery [51].

Ganglion cysts
Ganglion cysts may develop secondary to chronic SLAP tears and if anatomically favorable, can cause suprascapular nerve palsy via impingement. Literature have described arthroscopic decompression with a probe, shaver and ever a spinal needle [52, 53]. However, if it occurs due to an isolated SLAP pathology, these cysts have been shows to resolve spontaneously following a SLAP repair. In Youm at al case series, even patients with clinical weakness due to compressive neuropathy of the suprascapular nerves have been shown to make a full recovery following SLAP repair [54].


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How to Cite this article:Singh B, Bakti N. The Diagnosis and Management of Superior Labral (SLAP) Tears of the Shoulder: A Review Article. Acta of Shoulder and Elbow Surgery Jan – June 2017;2(1):15-21.

Prof. Bijayendra Singh

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Arthroscopic Long Head Biceps Tenodesis in Coracoid associated with its Transfer to the Conjoined Tendon

Acta of Shoulder and Elbow Surgery | Volume 2| Issue 1 | Jan-Jun 2017 | Page 7-10| José Carlos Garcia Jr, Alvaro Motta Cardoso Jr, Marcelo Boulos D. Mello

Authors: José Carlos Garcia Jr [1], Alvaro Motta Cardoso Jr [1]., Marcelo Boulos D. Mello [1]

[1]NAEON-Santa Catarina Hospital
[2]IFOR Hospital

Address of Correspondence
Dr. Jose Carlos Garcia Jr., MD, MSc, PhD
NÆON-Hospital Santa Catarina-SP-Brazil


Introduction: The knowledge of the long head of biceps tendon as a potential source of pain in the shoulder has been longstanding. However LHBT’s pathology and its treatment remains controversial. Current surgical options include tenotomy, tenodesis, or transfer. The author has presented a surgical technique of LHBT tenodesis in coracoid associated to its transfer to the conjoined tendon.
Methods: Patients were assessed before the surgeries using UCLA score. After surgery UCLA, SF-36 and raw scale for function, physical limitation and pain were evaluated 2 years after surgeries.
Results: The average UCLA changed from 22.00±0.69 to 33.14±0.52, p=0,0001. The average SF-36 6-month-after-surgery was 140.40±1.44. The minimal follow up was 2 years. There was no surgery failures.
Conclusion: The surgical procedure has achieved satisfactory results and it can be one more surgical option in order to treat the biceps pathologies. The author do not belive LHBT transfer isolated may be superior to its association with tenodesis in the coracoid.
Level of evidence: This is study has a level of evidence 4.
Key words: Arthroscopy, biceps, tenodesis, transfer.


The knowledge of the long head of biceps tendon (LHBT) as a potential source of pain in the shoulder has been longstanding [1-4].
When conservative management fails treatment options are either tenotomy or tenodesis. Tenotomy provides reliable pain relief, however its complications include muscle spasm in younger patients and cosmetic deformity in all ages [5-8].
In 1936 Gilcreest wrote about many different types of biceps tenodesis such as suture of the tendon to the short head of biceps, suggested by Bazy; suture to the coracoid process, suggested by Perthes, suture to the insertion of the pectoralis major, suggested by Hoffman and suture in the sulcus intertubecularis, suggested by Roloff9. The Gilcreest’s personal option was by combining the Bazy and Perthes techniques [9].
Many other LHBT surgical techniques have also been reported since them, however LHBT’s treatment remains controversial [2, 3] .
O`Brien suggested that the suture of the tendon to the short head of biceps could present superior healing when compared with the bony tenodesis. Other advantage is that it could also preserve the natural biceps axis [10].
When Gilcreest combined Bazy and Perthes techniques [5] he preserved the natural biceps axis [10] with the advantages of soft tissue healing and also added the advantages related to the bony tenodesis in a stronger and safer system [9].
All the ancient techniques mentioned above, unless the Gilcreest’s one, currently can be done by using minimally invasive procedures, with its related benefits [10].
The author developed an arthroscopic technique of LHBT transfer to conjoined tendon associated with its tenodesis on the coracoid`s tip and presents its results in this study.

From June 2008 to January 2009 15 patients underwent to the arthroscopic Gilcreest procedure in this service.
Inclusion Criteria:
Patients older than 18 years.
At least two years follow up
Patients with biceps pathology associated or not with rotator cuff lesions or acromioclavicular osteoarthritis.
Exclusion Criteria:
Patients with other shoulder pathologies
Patients that underwent to other surgical procedures after the tenodesis
Patients that refused to take part of this trial

Surgical Technique
The patient is placed on the beach-chair position on the operating room table. A standard posterior viewing portal is established and the arthroscope is introduced. Diagnostic arthroscopy is performed and an accessory portal in the anterior triangle is established.
At this point, the biceps tendon is inspected, including the anchor to the superior labrum. A probe is used to low the tendon allowing better visualization of its entire intra-articular portion.
The scope is located in the subacromial space and a decompression is performed by using a combination of shaver and radiofrequency. Visualization of the subacromial space and of the bicipital groove laterally is them possible. Other procedures such as rotator cuff reconstructions or suprascapular nerve release can also be performed at this time, if necessary.
A spinal needle is then used to localize a superior, anterolateral portal just anterior to the bicipital groove allowing introduction of devices to work in this space.
The coracoacromial ligament completely removed, allowing better access and visualization to the lateral aspect of the coracoid and conjoint tendon by using the arthroscope in the lateral portal. The subdeltoid space needs to be carefully cleared to better expose the conjoint tendon(figure 1). The scope direction changes to dowonwards until it faces the insertion of the pectoralis major insertion. At this moment the LHBT is cleaned just superiorly to the pectoralis major tendon using the probe and the shaver (figure 2). Bleeding is a frequent problem in this space and radiofrequency devices are used to stop local bleeding.

The biceps tendon is tagged in this space using a Caspary`s(Conmed/Linvatec®) device through a nylon 0 for making landmarks. The scope returns to the posterior portal through the intraarticular space and the biceps tendon is tenotomized from its origin on the superior labrum. The scope returns to the lateral portal and the LHBT is pulled out of the body using a grasper through the anterolateral portal (figure 3). Sometimes all the intertubecularis sulcus need to be released to allow biceps extrusion.
A 3mm anchor is inserted at the superolateral portion of the coracoid(figure 4). The anchor wires are pulled out through the same anterolateral portal where the tendon is. Cannulas are not recommended on this surgical step.
Using a Caspary`s (Conmed/Linvatec®-Largo-FL-USA) (figure 5), 2 fiber wire® (Arthrex®-Naples-Fl-USA) wires passes through the short head of biceps tendon just under the coracoid tip to the posterior portal.
Out of the body the LHBT is sutured using Krakov suture by using one wire from the suture anchor. The simple knot pushes the sutured tendon into the subdeltoid space to find the coracoid and the tenodesis is done.
Using a 18 gauge needle 2 nylon 0 wires are passed through the LHBT in its new location at the same level the fiberwires® have been passed in the short head.
The nylon wires guides the fiberwires® through the LHBT and the suture between both biceps heads are made using regular arthroscopic knots (figures 6 and 7).
II) Patients evaluation:
Patients were evaluated before the surgeries using UCLA score and six monts after surgery using the UCLA score, SF-36, raw scale for function, physical limitation and pain.
Patients were interviewed by phone 1 year and 2 years after surgeries using the raw scale evaluation for function, physical limitation pain and the presence of popey sign.
Data from UCLA were also checked at these times, patients with changes in UCLA were assessed again and just the last result was recorded.
Our minimal follow up was 2 years.
Statistic tests followed the characteristics of the curves.

Fifteen patients were enrolled in this study were 15 with tendinopathy of the long head of biceps tendon (LHBT) were chosen to be submitted to surgical treatment.
One patient was withdrawn because he did not approved his data for publication.
In 12 patients supraspinal tendon lesions were associated.
In 5 patients subscapular tendon lesions were associated.
No patients presented Popey sign after surgery.
UCLA two-year post surgery changed from 22.00±0.69 to 33.14±0.52, p=0,0001. The statistical test used was Wilcoxon matched-pairs signed rank test.
SF-36 two-year post surgery was 140.40±1.44. The raw scale of function two-year post surgery was 93.43%±1.33%. The raw scale for physical limitation two-year post surgery was 96.43%±2.04%. The raw scale for pain two-year post surgery was 94.64%±1.61.
The 1 year and 2 years after surgeries interview by phone used the raw scale evaluation for function, physical limitation pain, the presence of popey sign and patients were also questioned about possible changes in UCLA.
The interviews 2-yer-after-surgery revealed no changes for UCLA scores.
No overtensioning happened.
There was an anterior discomfort for extremes of adduction

The long head biceps tendon continues to play a controversial role in shoulder surgery. In fact, its exact role in shoulder kinematics has not yet been elucidated. Some authors believe that the tendon may play an important role in shoulder stability [11-13]. Others believe that the tendon is clinically insignificant, serving only as a vestigial structure [14-16]. Despite this controversy, it is commonly accepted that the biceps tendon can play an important role in shoulder pathology and serve as a pain generator in the shoulder. The surgical management of biceps tendon pathology remains equally controversial. Current surgical options include tenotomy, tenodesis, or transfer [2, 3, 17, 18]. Tenotomy provides reliable pain relief with the shoulder at rest 5-7. However, in younger patients, complications including cosmetic Popeye deformity and spasm of the biceps muscle belly were not uncommon.
Multiple techniques of LHBT fixation can be used to avoid these problems. Bone tunnels, bone anchors, staples, or interference screws are available options 3, [18-22]. Earlier techniques of transposition of the long head biceps to the conjoint tendon have involved direct tenodesis to the coracoid process [4, 17, 23, 24] reviving the description of Gilcreest in 1936.
O`Brien reported the LHBT transference as being a reliable option when focusing a closer reproduction of the native axis of pull of the biceps muscle and allow the long head and short head to share load. The transfer allows a soft-tissue healing, which may be more favorable than soft tissue to bone healing as it recreates the normal bungee effect of the superior labrum/biceps anchor complex. Finally, this technique provides the surgeon with direct visualization during tensioning and suturing helps prevent overtensioning of the tendon [2].
Our technique has associated the LHBT tenodesis into the coracoid to the O`Brien`s transfer technique in order to avoid loss of the surgeries. We added the tenodesis protection to the soft tissue healing purposed by O´Brien.
The coracoid tenodesis associated to transfer has presented higher difficulty than in the traditional humeral biceps tenodesis.
Some authors belive that if the LHBT natural location`s is the biceps groove in the humerus, moving the tendon can raise unknown biomechanical consequences [11, 12, 16, 17, 21, 23, 24].
However for others the transfer to the coracoid can be more favorable to the biceps natural axes and can be the best choice for the tendon healing [2].
Our experience suggests that in terms of healing and activities, the coracoid axis do not cause clinical problems, however this transference demands proper training and increases time to the surgical procedure.

Indeed our long term results are favorable, however the author do not believe this technique is better than other types of tenodesis.
The surgery increased time to the surgery and demanded very specific training.
This technique is a possible option for biceps pathology.


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24. Ozalay M, Akpinar S, Karaeminogullari O, Balcik C, Tasci A, Tandogan RN, Gecit R. Mechanical strength of four different biceps tenodesis techniques. Arthroscopy 2005;21(8):992-8.

How to Cite this article:JC Garcia Jr, AM Cardoso Jr, MB D. Mello. Arthroscopic Long Head Biceps Tenodesis in Coracoid associated with its Transfer to the Conjoined Tendon. Acta of Shoulder and Elbow Surgery Jan – June 2017;2(1):7-10.
Dr. Jose Carlos Garcia Jr Dr. Alvaro Motta Cardoso Jr Dr. Marcelo Boulos D. Mello

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Brazil and India – A New Collaboration through Acta of Shoulder and Elbow Surgery

Acta of Shoulder and Elbow Surgery | Volume 2 | Issue 1 | Jan-June 2017 | Page 1-2| Ashish Babhulkar

Author: Ashish Babhulkar [1].

[1]Deenanath Mangeshkar Hospital, Pune, India

Address of Correspondence
Dr. Ashish Babhulkar
Head of Dept. Shoulder & Sports Injuries
Deenanath Mangeshkar Hospital, Pune, India

Felix Ano Novo & a Happy new year to all. The beginning of a new year 2017 – brings us fresh challenges. Shoulder surgery has evolved from multiple surgery options in the past for say – Shoulder dislocation – to just a couple of options between a Bankart or a Latarjet. This is surely a sign of maturity and one would assume, culmination of our search for questions and solutions.
That is as far from truth as Trump is from Obama. As we establish gold standards for Rotator cuff repair & Bankart repair, we are faced with more complex issues with irreparable cuff tears and mega glenoid bone loss. Similarly, a shoulder surgeon is faced with diverse options in treating irreparable cuff tears in symptomatic patients. Lat Dorsi transfers, Allografts, human dermal matrix graft, and now superior capsular reconstruction & ultimate “solution” of a Reverse shoulder arthroplasty are few of the alternatives. Each is no doubt an ingenious procedure but how does a surgeon discern the best and most appropriate procedure for a given patient & given age for that patient. What leads a Japanese surgeon and my friend Teruhisa Mihata to relentlessly pursue Superior capsule reconstruction1, over a reverse Shoulder Arthroplasty or Lat Dorsi Transfer?
For a minute, if we accept the most complex instability is glenoid bone loss – As a surgeon I am faced with the options of an Open Latarjet – Congruent arc Vs conventional Latarjet, Iliac crest bone graft and Open Vs ArthroLatarjet. With each procedure being impressively successful, it’s virtually impossible to pick the exact effective procedure. With success rates in excess of 88%, what dictates a procedures superiority over the other2?
It will statistically be impossible for any double blinded study without an immeasurable sample size, to choose between the best type of Latarjet. So, whilst we wait for time to unravel the answers for the long-term results of say Superior capsular reconstruction or Arthrolatarjet, we ought to research and publish even more.
Am afraid, I shall finish with more questions than answers. However, that is exactly the scientific probity that I beseech of you. That is exactly why ACTA of Shoulder & Elbow must provoke your intelligence and seek more research articles.
The challenge in fact is multifold. One, to achieve research on a massive sample size to show a 1% difference between different techniques of cuff repair & Bankart techniques that are already Gold standards. Second, to achieve any amount of sample size for rarely done procedures such as Superior capsule reconstruction & Lat dorsi transfer is a daunting task. Third & finally, to wait for a longitudinal study over 30 years to find out that a given procedure was inappropriate.
Brazil & India – the emerging world, face similar challenges. Insurance shortage, economic depravation and rural healthcare deficit are gripping problems that developing countries face. In the midst of these healthcare challenges, we have innovated, delivered top class cutting edge treatment and continue to grow at such a rapid pace that the industry is compelled to stop and pay attention to such emerging countries. Data collection, pursuit of research and compulsive publication of techniques and basic sciences is our fundamental need.
Unlike the adage, “Cannot teach an old dog new tricks”, all of us, as Shoulder surgeons, must learn new techniques & tricks, as the final word for these unsolved issues is still not written. Surgical Skill and medical research are both joined at the hip and cannot exist without the other.
As the popular saying in Hindi – – Diligence is the mother of good luck.

Ashish Babhulkar
Head of Dept. Shoulder & Sports Injuries
Deenanath Mangeshkar Hospital, Pune, India


1. Mihata Teruhisa, Thay Q. Lee, Ph.D., Chisato Watanabe, Kunimoto Fukunishi, Mutsumi Ohue, Tomoyuki Tsujimura, Mitsuo Kinoshita: Clinical Results of Arthroscopic Superior Capsule Reconstruction for Irreparable Rotator Cuff Tears.Arthroscopy , Volume 29 , Issue 3 , 459 – 470.
2. Allain J., Goutallier D., Glorian C. Long term results of the Latarjet procedure for the treatment of anterior instability of the shoulder. J Bone Joint Surg Am. 1998; 80: pp841-852.

How to Cite this article: Babhulkar A. Brazil and India – A New Collaboration through Acta of Shoulder and Elbow Surgery. Acta of Shoulder and Elbow Surgery Jan – June 2017;2(1):1-2.

Dr. Ashish Babhulkar

Dr. Ashish Babhulkar

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Posterior Endoscopy of the Shoulder with the Aid of the Da Vinci Si Robot – A Cadaveric Feasibility Study

Acta of Shoulder and Elbow Surgery | Volume 2| Issue 1 | Jan-Jun 2017 | Page 36-39| Bijayendra Singh, N Bakti

Authors: Bijayendra Singh [1], N Bakti [1]

[1]Medway NHS Foundation Trust, Visiting Professor Canterbury Christchurch University.

Address of Correspondence
Prof. Bijayendra Singh,
Consultant Orthopaedic Surgeon,
Medway NHS Foundation Trust, Visiting Professor Canterbury Christchurch University, Medway, KENT


Introduction: The objective of this study is to present a cadaveric study with new possibilities of using the surgical robot in the daily practice of the shoulder surgeon, verifying which structures can be better visualized and manipulated at the posterior side of the shoulder.
Material and methods: Two fresh cadaver shoulders were used. The positioning of the shoulder was as like in a prone decubitus, with an arm in a position similar to that of elevation at 900. An incision was made in the skin on the trapezius muscle, palpated about 2cm from the axilla. Another 2 incisions were made more cephalic, one medial and one lateral in the arm next to the axilla forming a triangle. Through these 3 portals, tweezers were introduced for dissection and access to the muscle fascia. A cavity is created, since there are no natural cavities in this space. A trocar is introduced into each of the incisions, into the cavity formed. In the first portal on the trapezius muscle was introduced the camera of the robot Da Vinci SI, 8mm with optics of 00, and in the lateral and medial portals were placed the robotic working instruments.
Carbon dioxide was inflated at a constant 8mm Hg pressure through the chamber portal into the working cavity, stretching the soft tissues and opening the cavity. The work arms used the Maryland and De Bakey type dissecting tweezers and scissors, dissecting the lateral border of the latissimus dorsi muscle until its insertion, triangular interval, radial nerve, quadrangular space, and axillary nerve.
Conclusion: In this study the visualization of the desired structures was possible, without neurovascular lesions, suggesting that the use of robotic endoscopy may be a viable option for visualization of the quadrangular space and axillary nerve, as well as the radial nerve and the latissimus dorsi tendon.


Robotic surgery has been earning space and expanding its possibilities of use in the last years, it has been used for a long time [1, 2, 3], and is already present as routine in daily medical practice in several surgical specialties to treat many pathologies [4,5]. Within orthopedics, we highlight the use of robotics in microsurgery [6,7] and surgery of the shoulder and elbow [8, 9, 10].
The possibility of associating the robotic technology with endoscopy further increases the challenge and the possibility of less invasive treatment, allowing a faster recovery for the patient, consequently shorter time of hospitalization and less absence in work [11].
Advantages of this method include movement accuracy, high resolution imaging with three-dimensional vision, gas infusion rather than saline solution (better visualization), filtering of the surgeon’s tremor when manipulating objects, movement scaling and hand-free camera manipulation [12, 13, 14, 15]. In addition, there is the possibility of remote surgery (telesurgery) where the surgical team can treat a patient far away1, 2 or a surgical team may be composed of professionals located in different cities or countries, treating the same patient simultaneously.
Some shoulder pathologies that need to be surgically treated by the posterior side of the shoulder may need aggressive and traumatic exposure with extensive manipulation of soft tissues. The possibility to use a minimal invasive approach can potentially be important for both the time of rehabilitation and avoiding local soft tissue adhesions. In Addition, when performing a large posterior open approach, one needs the use of tensioned retractors in order to keep the surgeon’s field in a suitable manner. The use of these tensioned retractors can eventually damage the deeper muscle layer as well as other neurovascular structures [16, 17, 18, 19, 20].
The minimally invasive procedures have demonstrated decrease of adhesions, avoiding reoperations and physical therapies during long times. Indeed, this advantage mentioned above make these procedures cost-effectives [11].
Some examples of minimally invasive shoulder surgery, are the arthroscopy and endoscopy of the extra-articular anterior region of the shoulder are already been used for manipulation of the coracoid process for the arthroscopic Bristow-Latarjet procedure [21,22] and manipulation of the long head of the biceps tendon after its exit from the rotator interval, as for biceps tenodesis.
This study is following a tendency for less invasive approaches, once there are not many minimally invasive procedures publications for most of the posterior structures and pathologies of the shoulder.
In shoulder surgery, the use of robotic-assisted surgery for better identification of the quadrangular space of the shoulder, identification of the axillary and radial nerves, and better identification of the latissimus dorsi muscle has not yet been proposed. This would make it possible to perform procedures such as the release of compressive syndromes of the axillary and radial nerves and for make possible, muscular transfers, focusing the latissimus dorsi muscle.
The objective of this study is to evaluate the feasibility of this method for the practical and daily use in the posterior space of the shoulder, verifying which structures can be better visualized and manipulated.
This study aims to provide data that will allow the treatment of many pathologies such as Quadrangular space syndrome, radial nerve compressive neuropathies, and manipulation of the Latissimus Dorsi tendon by using this new technology.

Material and Methods

Two fresh cadaver shoulders were used for the study, and in both anatomical pieces, the same procedure was followed: the shoulder was positioned as if in a ventral decubitus, the arm being maintained in a position similar to 900 elevation.
An incision was made in the skin, about 1 centimeter, in the lateral border of the trapezius muscle, palpated about 2-3cm from the axilla. Two other incisions were made more cephalic, one medial and one lateral in the arm near the axilla forming a triangle (Fig. 1). Through these 3 portals, tweezers were introduced to access the muscular fascia where a cavity was formed through blunt dissection. This space was made for triangulation as an initial working cavity, once there are no natural cavities in this space.

A trocar and a canula were introduced into each of the incisions, in a common direction in the cavity formed. In the first portal on the trapezius, the camera of the Da Vinci SI robot (Intuitive Surgical, Sunnyvale, CA, USA), with an optic of 00, is introduced.
Carbon dioxide was inflated at a constant 8mm Hg pressure through the chamber portal into the working cavity, stretching the soft tissues and opening the cavity. The work arms used Maryland Bipolar Forceps 8mm (Intuitive Surgical, Sunnyvale, CA, USA), DeBakey Forceps 8mm (Intuitive Surgical, Sunnyvale, CA, USA) and Hot ShearsTM Monopolar Curved Scissor 8mm (Intuitive Surgical, Sunnyvale, CA, USA).
The first objective was to clean the area around the camera so that we could initiate the best dissection and identification of the initial working cavity. After this first stage, we began the search for the superior border of the latissimus dorsi muscle. Once it was found we dissected its superior border laterally, until its entrance deep into the medial border of the long head of the triceps and looking to the lateral border of the lateral head of the triceps, it is possible to visualize the triangular interval, between the teres major muscle/Latissimus Dorsi(cephalic), the long head of the triceps (medially) and lateral head of the triceps originating in the humerus (laterally). In this muscular interval it was possible to visualize the radial nerve (Fig. 2).

Continuing the dissection laterally in direction to the axilla, and deep into the deltoid muscle, and in the cephalic direction and superficially to the tendon of the teres major muscle, to its upper border, the quadrangular space was visualized, between the teres major muscle (caudal), teres minor (cephalic), long head of the triceps muscle (medially) and the humerus (laterally). In this space the axillary nerve could be visualized and identified in its path from anterior to posterior (Fig. 3).

Returning to the upper border of the latissimus dorsi muscle, a point taken as the initial reference for the identification of the triangular interval, it was possible to follow its superior border laterally, and deeply to the long head of the triceps, until the insertion in the medial and antero-medial region in the diaphysis of the Humerus (at this time associating the internal rotation movement of the humerus, to make easily the visualization of its insertional region in the humerus.
All structures visualized and described above: limits of quadrangular space and triangular interval, axillary nerve, radial nerve were identified. After the robotic procedures an open approach was performed to confirm that there was no lesion of any structure (as tendons, vessels or nerves).


As a result of this study, a successful visualization and manipulation of all target structures was obtained.
The study showed that it is possible to perform the procedures minimally invasively in the posterior region of the shoulder, with the help of the DaVinci robot (Intuitive Surgical, Sunnyvale, CA, USA)
There were no muscular or neurovascular lesions identified in this study.


The visualization of the desired structures was achieved, and after dissection and detailed identification of the structures it was confirmed that all structures described did not present visually identifiable lesions, which adds reproducibility to the method, although the postoperative functional evaluation is not possible in an anatomical model.
There are few similar studies in the area of ​​orthopedics, especially in shoulder and elbow surgery using the aid of robotics, a practice already more widespread in other surgical areas, but which have been gaining space and recent publications23, 24, 25.
The described neurovascular structures were identified in this study, in the similarly as that they were comparatively identified in other studies in the literature10, 23, 24, 25.
The visualization and partial manipulation of the latissimus dorsi muscle has already been reported, in order to aid the transportation of the muscular pedicle, with technique that was used as reference for our study25.
Axillary nerve identification has also been described6, 7, 10, making a contribution to our study and confirms the viability of the method.
The reproducibility of the method described here may aid in performing procedures for shoulder muscle transfers using robotic assistance.
Regarding bleeding, studies in live patients have shown that the air insufflation have been effective on avoiding bleeding9.
We hope to encourage further studies in the area, both in improve identification of anatomical structures and performance of procedures in anatomical models (cadavers), as well as the clinical applicability in the treatment of pathologies in the posterior region of the shoulder.


In this study the visualization of the desired structures was possible, without neurovascular lesions, suggesting that the use of robotic endoscopy may be a viable, safe and non-invasive option for visualization of the quadrangular space, axillary nerve, radial nerve and the dorsal muscle tendon.


1. Ballantyne GH, Moll F. The da Vinci telerobotic surgical system: the virtual operative field and telepresence surgery. Surg Clin North Am 2003;83:1293– 304, vii. 26. Southerland SR
2. Kavoussi, L R; Moore, R G; Partin, A W; Bender, J S; Zenilman, M E; Satava, R M. Telerobotic assisted laparoscopic surgery: initial laboratory and clinical experience. Urology; 44(1): 15-9, 1994 Jul.
3. Drake, J M; Joy, M; Goldenberg, A; Kreindler, D. Computer- and robot-assisted resection of thalamic astrocytomas in children. Neurosurgery; 29(1): 27-33, 1991 Jul.
4. Oldani, A; Bellora, P; Monni, M; Amato, B; Gentilli, S. Colorectal surgery in elderly patients: our experience with DaVinci Xi® System. Aging Clin Exp Res; 2016 Nov 26.
5. Gallotta, V; Cicero, C; Conte, C; Vizzielli, G; Petrillo, M; Fagotti, A; Chiantera, V; Costantini, B; Scambia, G; Ferrandina, G. Robotic Versus Laparoscopic Staging for Early Ovarian Cancer: A Case Matched Control Study. J Minim Invasive Gynecol; 2016 Nov 14.
6. Mantovani G, Liverneaux PA, Garcia JC Jr, Berner SH, Bednar MS and Mohr CJ. Endoscopic exploration and repair of brachial plexus with telerobotic manipulation: a cadaver trial. J Neurosurg. 2011 Sep;115(3):659-64.
7. Garcia JC Jr, Lebailly F, Mantovani G, Mendonça LA, Garcia J and Liverneaux PA Telerobotic Manipulation of the Brachial Plexus. J reconstr Microsurg 2012; 28(07): 491-494
8. Garcia JC Jr, Mantovani G, Gouzou S and Liverneaux P. Telerobotic anterior translocation of the ulnar nerve. Journal of Robotic Surgery. June 2011, Volume 5, Issue 2, pp 153–156.
9. Garcia JC Jr, Montero EFS. Endoscopic Robotic Decompression of the Ulnar Nerve at the Elbow. Arthroscopy Techniques. 2014; 3: 383-387
10. Porto de Melo PM, Garcia JC Jr, Souza Monteiro EF, Atik T, Robert EG, Facca S and Liverneaux P. Feasibility of an endoscopic approach to the axillary nerve and the nerve to the long head of the triceps brachii with the help of the Da Vinci Robot. Chirurgie de la main. 2013; 32: 206-9
11. Morgan JA, Thornton BA, Peacock JC, Hollingsworth KW, Smith CR, Oz MC, Argenziano M. Does robotic technology make minimally invasive cardiac surgery too expensive? A hospital cost analysis of robotic and conventional techniques. J Card Surg. 2005 May-Jun;20(3):246-51.
12. Byrn JC, Schluender S, Divino CM, et al. Three-dimensional imaging improves surgical performance for both novice and experienced operators using the da Vinci Robot System. Am J Surg 2007;193:519–22. 24.
13. Solis M. New Frontiers in Robotic Surgery: The latest high-tech surgical tools allow for superhuman sensing and more. IEEE Pulse; 7(6): 51-55, 2016 Nov-Dec.
14. Willems, Joost I P; Shin, Alexandra M; Shin, Delaney M; Bishop, Allen T; Shin, Alexander Y. A Comparison of Robotically Assisted Microsurgery versus Manual Microsurgery in Challenging Situations. Plast Reconstr Surg; 137(4): 1317-24, 2016 Apr.
15. Shademan, Azad; Decker, Ryan S; Opfermann, Justin D; Leonard, Simon; Krieger, Axel; Kim, Peter C W. Supervised autonomous robotic soft tissue surgery. Sci Transl Med; 8(337): 337ra64, 2016 May 4.
16. Pearle, Andrew D; Voos, James E; Kelly, Bryan T; Chehab, Eric L; Warren, Russell F. Surgical technique and anatomic study of latissimus dorsi and teres major transfers. Surgical technique. J Bone Joint Surg Am; 89 Suppl 2 Pt.2: 284-96, 2007 Sep.
17. Wijdicks, Coen A; Armitage, Bryan M; Anavian, Jack; Schroder, Lisa K; Cole, Peter A. Vulnerable neurovasculature with a posterior approach to the scapula. Clin Orthop Relat Res; 467(8): 2011-7, 2009 Aug.
18. Bertelli, JA; Kechele, PR; Santos, MA; Duarte, H; Ghizoni, MF. Axillary nerve repair by triceps motor branch transfer through an axillary access: anatomical basis and clinical results. J Neurosurg; 107(2): 370-7, 2007 Aug.
19. Lester, B; Jeong, G K; Weiland, A J; Wickiewicz, T L. Quadrilateral space syndrome: diagnosis, pathology, and treatment. Am J Orthop (Belle Mead NJ); 28(12): 718-22, 725, 1999 Dec.
20. Chalmers, Peter Nissen; Van Thiel, Geoff S; Trenhaile, Scott W. Surgical Exposures of the Shoulder. J Am Acad Orthop Surg; 24(4): 250-8, 2016 Apr.
21. Garcia JC Jr. Arthroscopic Bristow – Latarjet Procedure: Results and Technique after nine-year experience. Acta of Shoulder and Elbow Surgery Oct – Dec 2016;1(1):27-34
22. Garcia JC Jr, Cordeiro EF, Steffen AM, Gonçalves, MHL, Fink, LFS, Cortelazo, MJ. Arthroscopic Bristow-Latarjet Procedure (SS-05). Arthroscopy, June 2012Volume 28, Issue 6, Supplement 1, Pages e3–e4
23. Selber JC1, Baumann DP, Holsinger FC. Robotic latissimus dorsi muscle harvest: a case series. Plast Reconstr Surg. 2012 Jun;129(6):1305-12.
24. JH Chung et al. A Novel Technique for Robot Assisted Latissimus Dorsi Flap Harvest. J Plast Reconstr Aesthet Surg 68 (7), 966-972. 2015 Apr 02
25. Ichihara S, Bodin F, Pedersen JC, Melo PP, Garcia JC Jr, Sybille F, Liverneaux PA. Robotically assisted harvest of the latissimus dorsi muscle: A cadaver feasibility study and clinical test case. Hand Surgery and Rehabilitation 35 (2016) 81–84.

How to Cite this article:JC Garcia Jr, Gomes RVF, Kozonara ME, Steffen AM. Posterior Endoscopy of the Shoulder with the aid of the Da Vinci SI robot – a Cadaveric Feasibility Study. Acta of Shoulder and Elbow Surgery Jan – June 2017;2(1):36-39.

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Dr. Jose Carlos Garcia Jr

Dr. Márcio Eduardo Kozonara

Arthroscopic treatment of Glenoid Fractures

Acta of Shoulder and Elbow Surgery | Volume 2| Issue 1 | Jan-Jun 2017 | Page 15-21| Américo Zoppi Filho, Américo Zoppi Netto

Authors: Américo Zoppi Filho [1], Américo Zoppi Netto [1]

[1] Unicamp and University of Sao Paulo
[2] Consultant Shoulder Surgeons, Sao Paulo – Brazil

Address of Correspondence
Dr. Américo Zoppi Filho
Consultant Shoulder Surgeons, Unicamp and University of Sao Paulo


Arthroscopic joint surgery has recently undergone an exponential evolution, expanding its applications in traumatology allowing that ORIF techniques could be performed by using minimally invasive methods within the intraarticular space. However arthroscopic glenoid fixation for acute fractures have not been usually reported in the literature. This study presents a case series of arthroscopic fixation of the anterior glenoid. The six-month assessments using the UCLA Score, showed Good/Excellent results in 11/12 patients.
None of the patients presented recurrences of the dislocation and range of motion loses were minimal.
Keywords: Glenoid Fractures, Arthroscopic treatment, functional outcome.


Arthroscopic joint surgery has recently undergone an exponential evolution, expanding its applications in traumatology allowing that ORIF techniques could be performed by using minimally invasive methods within the intraarticular space [1].
The isolated fractures of the glenoid rim are many times associated with shoulder dislocation [2], and according to the abduction and rotation of the arm, can compromise small or larger parts of the bone [3] (small undisplaced fractures; larger and displaced fractures; cominutive fractures). Most of the time are single fracture or small cominuation; such characteristics allow a firm fixation using screws [4] and/or suture anchors [5] by using arthroscopic techniques.
Glenoid fractures associated with others parts of the bone, are treated different requiring an open reduction and internal fixation [6].
Most of the glenoid fractures reported thus have been associated with shoulder dislocation, and are results of high energy trauma [2].
The surgical procedures are indicated if the shoulder is unstable after reduction [3].
Small fragments (< 5mm) and patients 50 years of age and older, are best treated non-surgically, showing good results as pain and joint mobility are evaluated. Larger and displaced fragments, involving more than 20% of the articular surface, can curse with a unstable shoulder, requiring surgery [7].


From 2004 to 2015, we treated 12 patients (12 shoulders) with a displaced glenoid fracture, following a shoulder dislocation; 10 were men, and 2 women. Ages ranging from 20-61 years old, with a mean age of 33.2; 6 patients dislocated their shoulders in a motorcycle accident; 1 in a bike accident; 1 skiing and 4 falling from standing height.
The time between the trauma and the surgery was 3-14 days (mean 4.8 days). They all had articular instability, and a “loosen shoulder felling” during the ROM, at any degree.
In 9 cases, only 1 cannulated screw was necessary; 3 cases required 2 screws (Fig 2-A and Fig 2-B). In 2 patients, a labral repair was necessary to be added, using 1 suture anchor; 1 patient had a cominutive fracture, requiring the use of the 2 sutures anchors.


The arthroscopic treatment of glenoid fractures can be performed using the same technique and materials of labrum repair or cannulated screws.
We prefer the beach chair position; the optical goes on the posterior portal and instrumentation in the antero superior and antero inferior portal
The first step, and extremely important one, is to irrigate overly the shoulder cavity, to wash away the hematoma and any debris.
Usually, the bony fragment is displaced in an inferior and medial position in relation to the articular surface.
After identification, the fragment is cleared of any debris, allowing it’s free mobility, and a K wire is used as a joystick (Fig 1-A), aiding the reduction.
Preferably, the procedure should take place within few days of the trauma; any delay of that time can make the reduction harder, due to fibrous tissue.
Once the reduction has been achieved, the fragment is than fixed with a K wire (Fig 1-B); special attention should be taken not to fix the fragment in a too inferior position, risking any damage to the axilar nerve.

After the reduction and fixation of the fragment has been completed, we use K wire as a guide to place a cannulated screw of a smaller diameter as a final hardware fixation device. This is a particular difficult step; the apparatus to insert the screw is usually short, making the use of cannulas nearly impossible, especially in patients with a developed muscles in the shoulder area. Quite often the cannulas are removed, and a mini open access is used.
Other important detail is the location of the screw; the suture anchors or screws can be placed closer to the articular surface (near the border, in a extra articular position), avoiding any interference with the articular cartilage or mobility of the shoulder (Fig 2 A,B).
The post op care and rehab protocols were similar to glenohumeral instability.


The six-month assessments using the UCLA SCORE, showed Good/Excellent results in 11 patients. The oldest patient (61 years old) had post traumatic arthrosis (seen on imaging studies), with mild pain, mild instability, and small deficit ROM.
None of the patients presented recurrences of the dislocation. Loss of range of motion was minimal. A minimal discomfort was present in 11/12 patients mainly in the extremes of the movement.
Glenoid fractures are cause of recurrent anterior shoulder instability [8] thus the fracture fixation can be one of the best options for treating this traumatic condition.
There are just few papers related to this technique and this study’s data reproduces the current literature’s success [9].
The arthroscopic method for handle bony surgeries present advantage of the minimally invasive procedures [10] but will also need more training and arthroscopic skills [11].
This is one of the largest series in literature and presents promising results for treating acute fractures of the anterior glenoid rim by using a minimally invasive procedure.
To this moment the author has just assessed six-months post-surgery, however longer follow up is required in order to assess long term advantages and complications related to this procedure.


1 Giudici LD, Faini A, Tucciarone A and Gigante A. Arthroscopic management of articular and peri-articular fractures of the upper limb. EFFORT Open Rev. 2016; 1(9): 325-331.
2 Ideberg R, Grevsten S & Larsson S. Epidemiology of scapular fractures: Incidenceand classification of 338 fractures. Acta Orthop Scand. 1995 Oct;66(5):395-7.
3 Bigliani LU, Newton PM, Steinmann SP, Connor PM, McLlveen SJ. Glenoid rim lesions associated with recurrent anterior dislocation of the shoulder. Am J Sports Med. 1998;26:41–45.
4 Cameron SE. Arthroscopic reduction and internal fixation of anterior glenoid fracture. Arthroscopy. 1998;14(7):743-746.
5 Sugaya H, Kon Y and Tsuchiya A. Arthroscopy: Arthroscopic Repair of Glenoid Fractures Using Suture Anchors, Arthroscopy. 2005; 21(5), May, 2005: pp 635.e1-635.e5
6 Ada JR and Miller ME. Scapular Fractures: Analysis of 113 cases. Clin. Orth. Rel. Res. 1991; 269:174-180.
7 Yamamoto N, Muraki T, An KN, Sperling JW, Cofield RH, Itoi E et al. The stabilizing mechanism of the Latarjet procedure: A Cadaveric Study. J Bone Joint Surg Am. 2013; 95:1390-1397
8 Dana PP, Verma NN, Romeo AA, Levine WN, Bach BRJr and Provencher MT. Glenoid Bone Deficiency in Recurrent Anterior Shoulder Instability: Diagnosis and Management. JAAOS. 2009; 17(8):482-493.
9 Tauber, M., Moursy, M., Eppel, M. et al. Knee Surg Sports Traumatol Arthr. 2008; 16: 326-332.
10 Lafosse L, Lejeune E, Bouchard A, Kakuda C, Gobezie R & Kochhar T. The arthroscopic Latarjet procedure for treatment of anterior shoulder instability. Arthroscopy. 2007; 23:1242e1–1242e5
11 JC Garcia Jr. Arthroscopic Bristow – Latarjet Procedure: Results and Technique after nine-year experience. Acta of Shoulder and Elbow Surgery Oct – Dec 2016;1(1):27-34.

How to Cite this article: Filho A Z, Netto A Z. Arthroscopic treatment of Glenoid Fractures. Acta of Shoulder and Elbow Surgery Jan – June 2017;2(1):33-36.

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Dr. Américo Zoppi Filho


Management of Glenoid Bone Loss in Reverse Shoulder Arthroplasty

Acta of Shoulder and Elbow Surgery | Volume 2| Issue 1 | Jan-Jun 2017 | Page 28-31| Eric Wagner, John W Sperling

Authors: Eric Wagner [1], John W Sperling [1]

[1] Mayo Clinic Rochester-MN-USA

Address of Correspondence
Dr. Eric Wagner
Mayo Clinic Rochester-MN-USA


Reverse shoulder arthroplasty has greatly improved the outcome of patients who required a shoulder arthroplasty but have concomitant rotator cuff pathology. The most important aspect of reverse shoulder arthroplasty is securing a stable glenoid baseplate. This may be challenging in cases with severe glenoid bone loss and also in revision cases. This purpose of this review is to cover the diagnosis, evaluation, and treatment of glenoid bone loss in primary and revision reverse shoulder arthroplasty
Keywords: Reverse shoulder arthroplasty, glenoid bone loss, outcomes.


Since its introduction in France in the early 1990s and its approval by the Food and Drug Administration in 2003, the indications for the reverse prosthesis have expanded exponentially [49]. Reverse shoulder arthroplasty (RSA) has become a successful treatment option for patients with advanced glenohumeral arthritis and whose rotator cuff pathology precludes the use of anatomic style prostheses. Indications for the reverse arthroplasty include rotator cuff tear arthropathy, proximal humerus fractures and their sequelae, inflammatory arthritis, revision arthroplasty, and glenoid bone loss in the primary and revision settings [10; 20; 38; 39; 44].
In the setting of glenoid bone loss, the reverse prosthesis provides the surgeon with multiple options to achieve a functional, stable shoulder. However, all of these options are dependent on establishing a stable glenoid baseplate in the correct location and version. In the setting of advanced glenoid bone loss, this can be difficult to achieve. Furthermore, the semi-constrained nature of RSA places increased stresses on glenoid fixation, which may lead to glenoid component loosening and implant failure [5; 7; 8; 37; 40]. Although this is often encountered in the primary setting, severe glenoid bone loss can be particularly challenging in the revision setting.
This purpose of this review is to cover the diagnosis, evaluation, and treatment of glenoid bone loss in primary and revision reverse shoulder arthroplasty.

Glenoid Bone Loss: Etiologies, Evaluation, and Classifications

Etiologies of Glenoid Bone Loss
Understanding the etiology for glenoid bone loss is critical to effectively managing patients, as many of the causes present and progress with specific unique patterns. An in depth understanding enables the surgeon to both counsel patients about their nonoperative and operative options, the likelihood of disease progression, and their reconstructive options. Although proximal humerus fractures and their sequealae can be associated with glenoid bone loss, it is not as commonly seen as with the other indications for reverse shoulder arthroplasty.
In the setting of rotator cuff tear arthropathy, a superior glenoid bone loss pattern is often seen. Occurring in up to 40% of cases of rotator cuff tear arthropathy [10], advanced superior glenoid wear can often be difficult to recognize and plan for preoperatively. Failure to adequately address the superior erosion can lead to excessive superior tilt of the glenoid component, increasing the risk of scapular notching and subsequent glenoid component failure[13; 30].
In the setting of primary osteoarthritis (OA), posterior glenoid wear is often seen, leading to glenoid retroversion in severe cases. In Walch’s classic article, greater than 50% of patients with advanced shoulder OA had this abnormal glenoid pattern with some degree of subluxation45. In cases of severe posterior erosion and/or glenoid retroversion, failure to correct this bony defect can lead to poor outcomes related to poor function, instability, and glenoid loosening from malpositioned components with poor underlying bone stock [10; 22; 46].
In the setting of inflammatory arthritis and associated shoulder arthropathy, there is usually a central glenoid erosion pattern and subsequent medialization of the joint line. Reverse arthroplasty is often indicated in these patients, given their either torn or non-functional rotator cuffs as a result of the mechanical disadvantage from joint medialization, as well as their eventual proximal migration of the humerus over time [2]. In the setting of reverse arthroplasty, excessive medialization can lead to a biomechanical disadvantage, compromising shoulder function, stability and potentially increasing the incidence of scapular notching [4].
In the revision setting, glenoid bone loss can be of many different patterns, depending on the remaining bone stock after implant removal. When revising a hemiarthroplasty, the glenoid erosion patterns often mimic those seen in the primary setting, as previously described. During the revision of a total (anatomic or reverse) shoulder arthroplasty, prior baseplate loosening or removal of a well-fixed glenoid component has the potential to be associated with large glenoid bony defects. The bone loss pattern is variable, and when it is severe enough, can markedly compromise baseplate fixation and overall component stability [43].

Evaluation of Glenoid
A comprehensive preoperative evaluation is imperative prior to performing any type of arthroplasty in the setting of glenoid bone loss. Preoperative radiographic evaluation should include anteroposterior (AP) Grashey in internal rotation and external rotation, axillary, and scapular Y views. The axillary view is especially useful to assess for central, anterior, and posterior glenoid bone loss that might predispose to excessive anteversion, or retroversion. The AP view estimates the central defects that could lead to excessive medialization, or superior defects that might lead to implantation of the glenoid component with a superior tilt.
In addition to standard x-rays, a two-dimensional computed tomography (CT) scan (with slice thickness <1.5 mm) is critical to understand the glenoid bone loss pattern and morphology. The location and extent of the defect is determined using the standard centerline perpendicular to the glenoid surface, exiting on the anterior aspect of the scapular neck [3; 27]. The amount of bone available for central screw or post placement and location of the defect will allow the surgeon to plan their preferred method to reconstruct the glenoid preoperatively. It is also important to determine the effects of the arthritis on the native glenoid version, as studies have found increases in retroversion from 6-10o from arthritis alone [19]. Digital templating software may also be used to estimate not only the size of the new glenoid components, but also the need and size of augments or bone graft, in the primary setting [15; 42]. However, in revision surgery it is common for the surgeon to have to modify their strategy according to intraoperative assessment of glenoid bone loss after component removal.

Glenoid Bone Loss Classifications
There are multiple classification systems that have been established to describe the classic glenoid morphology patterns in the setting of glenoid bone loss.
The Walch classification describes the patterns of posterior glenoid bone loss, as seen in OA: A1 minor central glenoid erosion, A2 marked central glenoid erosion, B1 minor posterior glenoid erosion, B2 marked posterior glenoid erosion with retroversion (often above 10o), C glenoid retroversion >25o45. This is useful in the setting of larger glenoid defects, to help the surgeon compensate for retroversion and the potential need for baseplate augmentation posteriorly.
The Favard Classification describes the patterns of superior glenoid bone loss, as often seen in rotator cuff arthropathy: E0 superior humeral head migration without glenoid erosion, E1 concentric erosion of the glenoid, E2 superior erosion of the glenoid, E3 superior erosion of the glenoid extended inferiorly30. This is particularly useful when planning to compensate for superior wear and the need to avoid superior tilt of the baseplate.
The Levigne classification describes the patterns of central glenoid bone loss, as seen in rheumatoid arthritis: Stage 1 minor central erosion, Stage 2 central erosion to the level of the coracoid, Stage 3 central erosion medial to the level of the coracoid. This is useful in cases of marked medialization, when the surgeon desires to restore close to normal glenoid lateral offset, potentially improving shoulder function, stability, and incidence of scapular notching [4].
In the revision setting, the algorithm proposed by Wagner et al. helps to determine the need for and type of bone graft, or alternatively, component augmentation, with the goal of obtaining at least 30-50% implant-bone contact to facilitate adequate ingrowth [43]. Furthermore, as in primary arthroplasty, the graft, eccentric reaming, or component augmentations can be used to correct superior tilt, retroversion, or excessive medialization.

Glenoid Bone Loss: Primary Reverse Arthroplasty
Treatment Strategies
The strategies for addressing glenoid bone loss during reverse shoulder arthroplasty all have a goal of restoring glenoid version, offset, and tilt. Three of the strategies discussed in this article, which all have had moderate success in small short-term studies, include eccentric reaming, use of a lateralized implant, bone grafting, augmented components[14; 10; 23; 27; 33; 38; 43; 50].

Eccentric Reaming +/- Lateralized Implant
Although the algorithm was designed for the setting, its notion of attempting to obtain 50% contact between the baseplate and the glenoid is applicable to the primary setting (Figure 2). In cases of mild glenoid bone loss, eccentric reaming can be a very effective strategy to maximize the contact area of the implant-bone interface and potentially improve ingrowth [27]. A critical step when performing this technique is to determine the correct glenoid version and tilt, as estimated on preoperative imaging [19]. The center guide pin should be placed in the axis of the scapular spine, along the inferior part of the glenoid. Although it is important to maximize implant-bone contact, excessive reaming should be avoided due to the concern of removing unnecessary glenoid bone stock and over medializing the implant. In particular, there is concern with this technique regarding excessive violation of the subchondral plate thought to be important for glenoid component stability [14; 46]. This would cause the implant to be reliant on weaker cancellous bone, potentially compromising stability and ingrowth. Therefore, morselized corticocancellous allograft or autograft can be packed into any remaining small defects after the eccentric reaming has been finished [17; 43]. Another technique utilizes a lateralized prosthesis to overcome any medialization from the glenoid erosion and eccentric reaming [9].
There have been very few studies that have specifically examined the use of eccentric reaming alone or in combination with glenoid bone grafting. Correcting the underlying glenoid deficiency is critical to correct glenoid tilt and version. Furthermore, preoperative subluxation has been associated with poor outcomes after shoulder arthroplasty [22]. Klein et al. examined 56 reverse shoulder arthroplasties with glenoid bone defects treated with eccentric reaming, with 22 requiring augmentation with bulk autograft [27]. At 31 months follow up, patients had a significant improvement in pain scores and shoulder function, including ASES scores and shoulder motion. Those shoulders that required bone grafting did not have different outcomes compared to those that did not require grafting. Only 2 (4%) required revision surgery secondary to infection. In regards to preoperative subluxation, their review of 240 patients that underwent reverse shoulder arthroplasty, Wall et al. examined 33 patients who required a reverse prosthesis for osteoarthritis associated with static posterior humeral head subluxation [47]. These patients did well, with postoperative Constant score of 65, elevation of 1150, and low number of complications.

Glenoid Bone Grafting
In cases of moderate to severe glenoid bone loss where achieving 50% or greater contact area between the baseplate and native bone is not possible, glenoid bone grafting can help to make up for this bone loss (Figure 2). As detailed above, minor central or peripheral cases of glenoid bone loss can be managed utilized morcellized corticocancellous bone graft. However, in cases of larger defects, structural grafts are needed to achieve glenoid component stability, while restoring near anatomic version, tilt, and offset. The source of the structural graft in the primary setting is often from the resected humeral head [4; 28; 29; 32]. Alternatively, if there is insufficient bone in the humeral head due to prior pathology, trauma, or surgery, the autologous tricortical iliac crest or allogenic structural graft can be utilized1; [25; 33].
It is critical for the surgeon to preoperatively plan the desired reconstruction in these cases of severe glenoid bone loss. In cases of superior glenoid bone loss, it is critical to avoid superior tilt and achieve at least neutral, or even slight inferior glenoid tilt with the use of a structural graft [29]. Peripheral defects require structural grafts compensate for excessive glenoid anteversion (anterior) or retroversion (posterior) [43]. Central defects require bone graft to restore glenoid offset through lateralizing the prosthesis4. Furthermore, in cases of marked medial wear, it is important to have at least 8-15 mm of bone available for the central peg and peripheral screw purchase [4; 31; 35]. In fact, a finite element analysis by Hopkins et al. suggested 16-30 mm of screw purchase in bone lead to a 30% reduction in micromotion18. In all of these cases, the structural bone graft is contoured prior to implantation, then either secured with the baseplate and screws alone, or in combination with separate screws outside the baseplate. Although the indications for glenoid bone grafting with the reverse arthroplasty are still evolving, cadaveric studies involving the anatomic arthroplasties suggest cases of 15o or more of glenoid retroversion should be corrected with structural bone graft [6; 11].
In anatomic total shoulder arthroplasty, glenoid bone grafting is associated with increased rates of complications, as glenoid deficiency leads to increased rates of glenoid retroversion, failure of graft incorporation, and glenoid component loosening leading to resultant revision surgery [16; 24; 33; 34; 41]. To date, there remain few studies examining the results of glenoid bone grafting using the reverse prosthesis. Although not in the setting of glenoid bone loss, Boileau et al. examined 42 patients who underwent structural humeral head grafting to increase the lateralization of glenoid components in in patients without marked bone loss4. At a minimum of 2 years follow-up, no graft resorption or glenoid loosening occurred, 41 of 42 had full incorporation of the graft, and only 19% rate of scapular notching.

Augmented Component
The role of augmented glenoid components is controversial, as its specific indications continue to evolve. Its use has been described in anatomic [12; 21; 26; 34; 36; 48] and reverse [23; 50] shoulder arthroplasty, mostly in the setting of a marked peripheral bone defect (E.g. Walch B2) or with severe glenoid destruction requiring a custom made, patient specific implant. In anatomic shoulder arthroplasty, Rice et al. examined 14 posteriorly augmented keeled polyethylene glenoid components [34]. At a mean 5 year follow-up, patients achieved predictable pain relief and restoration of shoulder function, but had a relatively high rate of unsatisfactory results from recurrent instability and posterior subluxation. Two other small series by Gunther et al.[12] and Sandow et al.[36] reported on custom made augmented glenoid components, demonstrating better short-term results in series of 7 and 10 patients, respectively.
There remains a paucity of long-term studies examining the use of augmented glenoid components, particularly with reverse shoulder arthroplasty. Undoubtedly, there is tremendous potential in cases of severe medial or peripheral bone loss, however, further investigation is required to better elicit its role in reverse shoulder arthroplasty.

Glenoid Bone Loss: Revision Reverse Arthroplasty
Although there remains a need for further study regarding glenoid bone loss and the reverse prosthesis in the primary setting, there is even less information regarding its use in the revision setting of glenoid bone loss. Neyton et al. reported on the early outcomes of 9 patients who underwent revision reverse shoulder arthroplasty with glenoid bone grafting33. At 31 months follow-up, patients had a relatively low Constant Score, but had significant pain relief without signs of glenoid loosening, graft failure, or need for revision surgery. Kelly et al. examined 28 patients who underwent revision shoulder arthroplasty using the reverse prosthesis, with 12 shoulders treated with glenoid bone grafting [25]. Although their series reported a complication rate of 50% and a 23% revision rate at 34 months follow up, there was a high level of satisfaction in this complex patient population with 29 of 30 shoulders with a stable prosthesis at last follow up.
We reported on our outcomes of 41 patients who underwent glenoid bone grafting in the revision setting utilizing a reverse prosthesis [43]. At a mean 3 years of follow-up (range, 2-5), 7 (18%) required revision surgery with the majority (n=4) for glenoid loosening. Furthermore, 6 patients had signs of moderate or severe glenoid loosening at last radiographic follow-up, with factors such as increasing BMI, smoking, and a lateralized implant center of rotation increasing the risk. However, patients that did not undergo revision surgery had predictable pain relief, improvements in their shoulder motion, and high satisfaction. It should also be noted that only 5 patients were treated with structural grafts, potentially leading to the higher rates of glenoid loosening.

Bone Grafting Treatment Algorithm in Revision Reverse Arthroplasty
From our past experience, we have a proposed treatment algorithm (Figure 1) [43]. In patients that the glenoid is felt to be inadequate for stable fixation in an acceptable position, glenoid bone grafting is strongly considered. Implant-bone contact should be maximized, as well as preserving stability and shoulder motion. In cases with a small glenoid defect, a smaller baseplate can be utilized to maximize contact with the glenoid surface, while filling in the remaining defect with corticocancellous graft. However, in larger bone defects, a larger baseplate is utilized in combination with a structural graft.
As mentioned previously, structural autograft or allograft can be utilized for a variety of glenoid bone defect locations. Larger peripheral defects should be augmented by structural grafts to restore version and improve implant-bone contact. Superior defects predispose to superior tilt, and therefore, morselized (for smaller defects) or structural (for larger defects) can be used to restore neutral or inferior tilt and reduce the risk of scapular notching. And finally, large central (or global) deficiencies predispose to medialization, and thus require structural grafts to restore the natural lateral offset. We recommend if 80% of the undersurface of the glenoid baseplate is not in contact with the baseplate, morselized bone grafting is considered, while structural graft is considered in cases where less than 30%-50% of the component is in contact with the glenoid to augment the glenoid contact and fixation.


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How to Cite this article:Wagner E, Sperling JW. Management of Glenoid Bone Loss in Reverse Shoulder Arthroplasty. Acta of Shoulder and Elbow Surgery Jan – July 2017;2(1):28-32.

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Dr. Eric Wagner

Dr. John W. Sperling

Long Head of Biceps, a vestigial structure?

Acta of Shoulder and Elbow Surgery | Volume 2| Issue 1 | Jan-Jun 2017 | Page 22-27 | José Carlos Garcia Jr, Cássio V. Nunes, Maurício de Paiva Raffaelli, Arthur Doi Sasaki, Samir Hussem Salem, Sergio Rowinski, Mario Pina

Authors: José Carlos Garcia Jr [1], Cássio V Nunes [1], Maurício de Paiva Raffaelli [1], Arthur Doi Sasaki [1], Samir Hussem Salem [1], Sergio Rowinski [1], Mario Pina [2]

[1] NAEON-Santa Catarina Hospital
[2] Dep. Paleontology University of São Paulo

Address of Correspondence
Dr. Jose Carlos Garcia Jr., MD, MSc, PhD
NÆON-Hospital Santa Catarina-SP-Brazil


Long head of biceps has unique position both in terms of anatomy as well as function. Many regards is as important structure that helps in stability of the shoulder and also act as a shoulder depressor. Others have mentioned that tendodesis or tenotomy of LHB does not have any adverse functional impact on the shoulder joint. This raises the possibility that LHB is probably a vestigial structure which is diminishing in its role with evolution. To study this hypothesis a group of orthopaedic surgeons along with paleontologists studied the evolution of LHB by studying various mammals. It appears the in quadrupeds the LHB had important function of providing passive stability however in bipeds there is no need for passive stability and LHB may actually limit range of motion. Although this restriction may still work as beneficial in avoiding excessive motion but the exact importance cannot be justified. Moreover as the clinical studies have shown tenodesis or tenotomy of LHB has not deleterious effect on shoulder, it seems the hypothesis of LHB to be a vestigial organ has good grounds for more studies.
Keywords: Long Head of Biceps, Vestigeal organ, Paleontology study, evolution.


The long head of biceps (LHB) is one of the main anatomical structures at the shoulder, and it’s pathological conditions represent important causes of pain and disabilities, not only in the shoulder, but on the arm as well.
Many authors have reported the importance of the LHB in stabilizing the shoulder, and in acting as a depressor over the humeral head. These functions would prevent both glenohumeral translation, and humeral head elevation. Thus, according to such authors, it would seem quite rational to preserve the LHB, during any shoulder surgery, in order to avoid shoulder osteoarthritis, and rotator cuff lesions.
However, during daily practice, among many shoulder surgeons around the globe, surgical techniques treating the LHB with both tenotomy or tenodesis have lead to very satisfactory results, without any report of shoulder instability or osteoarthritis, after such LHB procedures[1].
A recent animal trial, that used a rotator cuff lesion model, including supraspinatus and infraspinatus tendons, compared the results of biceps tenotomy and a control group. Surprisingly, the most impressive result of such trial was that there was a protective effect in shoulder cartilage on the tenotomy group[2]. Other important data extracted from that paper was that there was a favorable difference in the group where the biceps was preserved, but only in the beginning of the study, once such difference simply disappeared over time[2]. Still, mechanical and histological properties of the subscapularis tendon also changed comparing the 02 groups, being worse in the control group, in which a biceps tenotomy was not done[2].
Nevertheless, many other authors have already theorized that the LHB is useless, remaining just as a vestigial structure, on the shoulder[3-5].
In this way, our main question, to better understand LHB, is : Can the biceps phylogeny, so as it’s evolutionary comparative study, help us to understand whether the LHB has an important function at the shoulder, or whether would it be just a vestigial structure?
Seeking for such response, the authors reviewed the comparative anatomy of the shoulder and the proximal biceps tendon during evolution, assessing and comparing anatomy and physiology, focusing into the proximal biceps tendon.

Material And Methods

The first step of our study was to define when did the proximal biceps tendon first appeared during evolution, and what would be it’s initial and original function. The authors hypothesized that, figuring out which was the first animal, from the chordata’s phylum, that presented a rudimentary upper limb with a rudimentary biceps, one would be able to better understand LHB modications and adaptations, during evolution, until it’s current presentation in the human being.
Such data was obtained by bibliographical study, in cooperation with the Paleontology Department of the University of Sao Paulo-Brazil.
Mammalians of our current age were then assessed, and a comparative anatomical and physiological study was done, regarding the LHB.
A special attention was paid to the primate’s shoulders assessments, mostly those ones closer to the homo sapiens.
All data was discussed with paleontologists from the Paleontology Department of the University of Sao Paulo-Brazil, and both observational Darwinian and neodarwinian approaches were applied over such data.


The first animals to take part of this study were from the Paleozoic era, which lasted from 542 to 251 million years ago. The Ostracoderm pteraspidomorphi, an ancestor of the fishes, presenting very rudimentar fins, was the first animal assessed to present some kind of upper limb. Ostracoderms evolved to Anaspids, extinct fishes which presented shorter paired anterior fin-folds. As per Paleontology, such paired anterior fin-flods would have originated fish fins as we know, today. On the Silurian period (443 to 416 million years ago), Acanthodii, a class of extinct fishes, sharing features with both bony fish and cartilaginous fish, evolved to better structured anterior fin-folds. However, Sarcopterygians (a class of lobe-finned fish, that would evolve to tetrapods, beings with four limbs), from late Silurian period, were those that presented the primary forms of a radius and a ulna, within their anterior fins. Using these osseous structures, these ancient fishes were, then, able to easily change their direction while moving under water, by pronation and supination of their anterior fins.
Such movements (pronation and supination) were originally performed by an ancient kind of biceps, originated on the humeral supinator process, or directly on the coracoid bone[6] (Fig. 1)[7].
Anyway, changing from navigating under water to a body that enables an animal to move on land was one of the utmost remarkable changes in evolution[8]. Such gain has been one of the most studied and understood transitions in evolution. Still, it’s important to mention that knowledge about such transition is achievable due to the existence of many transitional fossils that have been found, and due to their respective phylogenetical evolutionary analysis [9].
Sarcopterygians, as said above, evolved to tetrapodomorph fishes, in the late Devonian period (416 to 358 million years ago). These transitional fishes presented rudimentary arms, shoulders and hands. The oldest tetrapodomorph fish fossil known is the Kenichty, dated as 395 million years old. Other latter tetrapodomorphs, as the Gogonasus and the Panderichthys, are dating 380 million years old [10].
These animals used their fins to move in tidal channels and shallow waters.
Bodies of the Tiktaalik, a tetrapodomorph fish, that existed around 375 million years ago, suggest that locomotion using anterior limbs was originated in water before terrestrial adaptations [11]. The text of Shubin et al [12] reports the Tiktaalik’s upper limb functions and evolution, as follows: “Glenohumeral architecture and trans-coracoid musculature augment flexion and stability at the shoulder joint; a broad and deep posterior glenoid allows transmission of substantial propulsive stresses through the pectoral girdle; a robust coracoid plate provides broad areas for flexor muscle origins; elaborate ventral processes on the humerus represent extensive surface area for flexor insertions; flexion/extension, pronation/supination and rotation are possible at the elbow. Notably, the highly mobile yet robust distal fin segments could provide a stable but compliant extremity that could conform to complex and varied substrates.” Small movements for prono-supination were possible because of the radius translation along the humeral facet, in this animal [12].
These tetrapodoforms presented anterior limbs very similar to the sirenians (an order of aquatic herbivorous mammals that have forelimbs resembling paddles), as shown in A and C (Fig. 3). So, from a morphological point of view, all such changes happened to make prono-supination something real. Still, according to some authors, possibly the biceps could already exist in these animals, coming from the coracoid bone with a double function : supination, and fair abduction/extention [12].
On land, the first real tetrapods had to live as opportunists. They could reach land from tidal flats, and they in fact had some had facility in hunting marine animals that were brought by the tide [13]. Regarding chemical aspects, the evolution of tetrapods 1 has been related to the expression of HOXD13 gene and/or to the absence of actinodin 1 and actinodin 2 proteins[14,15].
After tetrapods definitely reached land, the necessity of velocity and the need of faster movements required that evolution moved forward. And, that become possible once evolution changed some anatomical characteristics that would make motion easier : rotating internally the humerus, pronating the radius over the ulna, and leaving fingers to the front, evolution allowed those animals to have better motion and motion control B,D,E(Fig. 3). That is seen in Acanthostegas, an extinct kind of tretrapod, considered the first vertebrate animal to have recognizable limbs (Fig.4). Such changes were the evolutionary answers to the new terrestrial demands of these animals.
The locomotion of these ancient tetrapods was defined by studies of tracks of walking, along the bottom of shallow waters [17]. The Carboniferous period (from 360 to 299 million years ago), is that one in which the amphibians really appeared, having limbs with digits and other adaptations for terrestrial life.
The number of digits was standardized by natural selection as five[17]. The current scapula, as we know, evolved from the fusion of three bones : the coracoid bone (also described as the metacoracoid), the procoracoid and the scapula(Fig. 5). It’s, in fact, interesting to mention that such 03 bones worked, respectivelly, like the ischium, the pubis and the ilium in the hip (Fig. 6).
The Pelycosaurs (large extinct reptiles of the late Carboniferous period, typically having a line of long bony spines along the back), were one of the most important evolutions of the amphibians. They presented their glenoid and humerus parallel to the ground, and robust bones for strong upper limb muscles (Fig. 7).
After the Carboniferous period, it came the Permian period. The Permian period was a geological period from 298,9 million years to 252 million years ago, and refers to the last period of the Paleozoic era. Over the Permian period, Cynodonts appeared on earth. Cynodonts were mammal-like reptiles, with well-developed and specialized teeth [18]. Some traits, seen today as unique to mammals, had origin in Cynodonts and in Therapsids, extinct reptiles which are related to the ancestors of mammals [18].
Cynodonts had their four limbs extending vertically beneath the body, in an upright posture, differently from the sprawling posture of other animals. The glenoid and humerus position followed this evolution rotating inferiorly(Fig.8).
Since the Pelycosaur (large extinct reptiles of the late Carboniferous period, typically having a line of long bony spines along the back), the coracoid bone (also known as metacoracoid) presented an expansion that have been related to conjoined tendon muscles in almost all current mammalians[18].
Coracoid have varied in many features during evolution, including size, curvature, and shape. These coracoid variations are related to functional differences of the biceps and coracobrachialis muscles among species of different habits[19-22]. Still, it’s important to mention that the coracoid expansion occurred in the same axis of the humerus in all the primitive mammaliforms and mammalians, in a way that elbow flexion muscles could act in the same mechanical axis as the humeral axis[19-22].
The rotator cuff appears in evolution together with the beginning of bipeditism. Infraspinatus was the first tendon to be developed in the shoulder, specially to give stability for an articulation with so many degrees of movement, and with less bony stability, when compared to the hip. Supraspinatus was added after, to improve such stabilization[23].
The ancient mammals presented a biceps tendon coming from the coracoid bone, on the scapula, and passing between these two muscles mentioned above (infra and supraspinatus), adding some degree of passive stability for the quadrupeds’ shoulders. The ancient and the current quadrupeds mammals, like the horse, present just one head of the biceps (Fig.9).
However, continuing the evolution to the humans, primates started using the erect position, and that meant two important repercussions on the shoulder [24]:
1) The upper limb (previously, the anterior limb) gained more movement, and passive stability lost mostly of it’s utility, when we compare primates to quadrupeds. That happens because passive stability means movement restriction, what was good for quadrupeds (that had to do only flexion/extension on their shoulders) and what was not that good for bipeds, who now would have to use their shoulder to many more movements, like aduction/abduction, and elevation.
2) Coracoid migrated anteriorly, keeping the same axis of the humerus, as happens in evolution, since the ancient fishes.
Once bipeds started to exist (primates, and men), the proximal biceps tendon was divided in two ones : the LHB, and the short head (conjoined tendon). The LHB continued to exist in the original biceps position, as it had always been in quadrupeds – that means, between the turbercles. That would, in fact, help on static shoulder stabilization; anyway, such LHB position, now on bipeds, could negatively affect gain of motion, once the original biceps tendon function was, in quadrupeds, to stabilize the shoulder, avoiding movements different from flexion/extension.
Monkeys presenting a wider shoulder range of motion tend to present a medialized LHB, when compared to humans. More than that, some monkeys even present their shoulder with absence of the LHB [24].
In the recent decades, the human being has increased his activities using the upper limb, specially in sport playing. The SLAP lesion, for example, is a good condition in which we can understand how the LHB can present negative influences in the shoulder, once the individual starts practicing activities with a higher shoulder ROM.
Still, we must not forget that the evolutionary response to improve the dynamic stability of the shoulder, in bipeds, was the development of the rotator cuff [23].
Rotator cuff adaptations have been suggested to happen in experiments using tenotomy of the LHB, in rats. Even such animal, a rat, who has a rotator cuff, and who uses less his upper limbs compared to humans, easily adapts to living with a tenotomized LHB, suggesting that the LHB have become more a vestigial structure that impedes movements on the shoulder than a necessary structure for stabilization [2].
In humans, biceps tenotomy and tenodesis have presented good results for pain control, with no repercussion in shoulder stability. That is particularly true when the most ancient active shoulder stabilizer, infraspinatus, is present.
In primates, rotator cuff presents 4 strong muscles, providing active shoulder stabilization, and a wide range of motion(Table 1).
In quadrupeds, even since the ancient Pelycosaurs, the biceps tendon never presented angles near 90º, like the LHB has, in it’s intra-articular position, in humans; instead, in such animals, the biceps tendon presents an angle close to 0º (Fig. 9). In fact, almost all current quadrupeds mammals present only a single head of the biceps tendon, that has near 0º of angulation, from it’s bony origin to the muscle belly.
As said above, biceps tendon has an important stabilization function, in quadrupeds’ shoulders.
In some primates, the LHB presents angulation of 90º, with possible repercussions in it’s health.
Hence, once we consider that the the conjoined tendon acts, mechanically, parallel to the long axis to the humerus (just as the LHB had always worked, in quadrupeds) and once we consider that the rotator cuff presents full capacity to offer to the shoulder active motion and stability, we can suggest that the LHB is a vestigial structure – which is, by definition, a structure that “had an important function in the past, but that has lost it’s importance, in the course of evolution”.
The proximal biceps tendon (LHB) was important in quadrupeds, allowing the shoulder to be stable; however, it loses it’s importance in bipeds, which need wider upper limb movements, and which have rotator cuffs, providing dynamic stabilization to their shoulders.
Other important point to be considered is the fact that the human coracoid and conjoined tendon, that keeps it’s angle near 0º, is a healthy tendon with whimsy pathologic affections.
Keeping this in mind, one can conclude that, in the human being, that present a strong rotator cuff, and whose shoulder needs a wide range of motion, the LHB, whose intra articular angulation is near 90º, not only can bring many problems to the shoulder, but also can be considered to be just a vestigial structure.
This conclusion supports many papers in literature, that describe biceps tenodesis and tenotomies with no functional negative repercussions to the patients.
Still, published papers suggest that a LHB tenotomy corrects the LHB axis, putting it in concordance to the axis of the humerus. Biceps tenotomy and tenodesis is widely known to diminish shoulder pain, with absent or minimal strength loses [25].


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How to Cite this article: JC Garcia Jr, Nunes CV, Raffaelli MDP, Sasaki AD, Salem SH, Rowinski S, Pina M. Long Head of Biceps- a Vestigial Structure? Acta of Shoulder and Elbow Surgery Jan – June 2017;2(1):22-27.

Dr. Jose Carlos Garcia Jr

Dr. Cássio V. Nunes

Dr. Mário Pina

Dr. Arthur Doi Sasaki

Dr. Samir Hussem Salem

Dr. Sergio Rowinski

Dr. Maurício de Paiva Raffaelli

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