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The use of Reverse Shoulder Arthroplasty for treatment of Chronic Shoulder Dislocations

January 10, 2017/0 Comments/in Uncategorized /by ASESADMIN2016

Acta of Shoulder and Elbow Surgery | Volume 2| Issue 1 | Jan-Jun 2017 | Page 11-14| Alexandre de Almeida, Rodrigo Zampieri, Pedro Guarise da Silva, Nayvaldo Couto de Almeida, Ana Paula Agostini Authors: Alexandre de Almeida [1], Rodrigo Zampieri [1], Pedro Guarise da Silva [1], Nayvaldo Couto de Almeida [1], Ana Paula Agostin [2] […]

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

January 10, 2017/0 Comments/in Vol 2| Issue 1| Jan-June 2017 /by ASESADMIN2016

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 […]

The use of Reverse Shoulder Arthroplasty for treatment of Chronic Shoulder Dislocations

January 10, 2017/0 Comments/in Uncategorized /by ASESADMIN2016

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

January 10, 2017/0 Comments/in Vol 2| Issue 1| Jan-June 2017 /by ASESADMIN2016

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The use of Reverse Shoulder Arthroplasty for treatment of Chronic Shoulder Dislocations

January 10, 2017/0 Comments/in Uncategorized /by ASESADMIN2016

Authors: Alexandre de Almeida [1], Rodrigo Zampieri [1], Pedro Guarise da Silva [1], Nayvaldo Couto de Almeida [1], Ana Paula Agostin [2]

[1] Pompeia Hospital, Caxias do Sul, RS, Brazil
[2]Pediatric M.D. at Caxias do Sul University, Caxias do Sul, RS, Brazil

Address of Correspondence
Dr. Alexandre de Almeida:
Rua Vitório Buzelatto, 222/601. Caxias do Sul, RS, Brazil.
Zip: 95020290.
E-mail: bone@visao.com.br

Abstract

Background: The chronic shoulder dislocation is a serious condition that cuts the upper limb function and puts it in a bad position for use of the elbow and hand. The mechanical changes due to the time that the joint is dislocated are irreversible and difficult to management. The surgical procedure for treatment this condition is generally salvaging procedures and has limited results mostly when the patient has limited healing capacity by age.
Methods: We evaluated three (3) patients with anterior chronic dislocation of the shoulder that underwent surgical treatment with Reverse Arthroplasty. The average age was 68 years, with the youngest patient 64 years old and the oldest, 77. The average period in which the shoulders were dislocated was 15 months (minimum of 4 and maximum of 24 months). The mean postoperative follow-up was 29.3 months (12 months minimum).
Results: Surgery was performed with a mean time of 123 minutes and one patient (33%) required blood transfusion. An average active flexion of 103 degrees and an average of 10 degrees of external rotation was reached. Internal rotation of the upper limb reaching the spinous process of the L4 was achieved in average. The mean UCLA index was 24 and 66% of patients were capable of activities of daily living. The complication rate was 33% with a transient axillary neuropraxia for 30 days.
Conclusion: The self-stabilization of the Reverse Shoulder Arthroplasty can lead to the short-term satisfactory results in the treatment of anterior chronic dislocation in elderly people.
Keywords: Reverse shoulder arthroplasty; dislocation;fractures, sequelae; posttraumatic; shoulder dislocation; shoulder replacement.

Introduction

Dislocation of the scapular-humeral joint is a condition that, when neglected, becomes an unwieldy condition where the prognosis is poor[1-5]. It is classified as type 2 of Walch Fracture-Sequela Classification [6].
Literature is controversial about the definition of chronic dislocation of the shoulder joint (CSD). Schultz et al[7] considered CSD 24 hours after the trauma. Rowe and Zarins[8] recognized as chronic the dislocation with at least three weeks of evolution. Postacchini and Facchini[9] defined as chronic the dislocation diagnosed after 45 days.
The treatment of this condition is divided between anatomical and arthroplastic surgical procedures. Anatomical procedures preserve bone stock and try to maintain the reduced joint functional. The arthroplasty procedures require the use of the muscule-capsular stabilizing envelope, which is damaged, making it difficult to maintain a stable and functional joint [1,10-13].
The objective of the study is to evaluate the médium-term result of the treatment of CSD with Reverse Shoulder Arthroplasty (RSA).

Methods
From January 2013 to September 2014, three patients presenting chronic anterior dislocation of the shoulder joint underwent surgical treatment by using RSA at the Shoulder and Elbow division of our institution. Patients, on the occasion of their admission for surgery, were informed and consented the use of their medical records data for scientific research. There was the release of the ethics committee of the institution involved in the study.
The average age of the sample was 68 years and the average length of shoulder dislocation was 15 months (minimum of four and maximum of 24 months).
The preoperative physical examination demonstrated, by inspection, a characteristic deformity of the anterior shoulder dislocation, function limited by the blockade of motion and the anomalous position of the upper limb. The patients had no neurological deficit (Fig. 1).
The surgical procedures were performed by the same surgeon in the “beach chair” position by a deltopectoral access. The brand of the arthroplasty was Exactech in two cases and Zimmer in one case. Two humeral stems were cemented and one uncemented. It was not possible to perform the closing of Subscapularis tendon in the three cases. The average operative time was two hours and three minutes (123 minutes) and there was the need for blood transfusion in one patient (33%) (Fig. 2).
The variables used for the study were: age, sex, operated side, range of motion, the index of UCLA and presence of alcoholism.
The data were analyzed by the arithmetic averages and proportions.

Results
The average age of patients included in the study was 68 years. The youngest patient was 64 and the oldest, 77 years old. Two patients were male and one was female. The operated side was the right side in all patients and all patients were right handed.
Postoperative clinical evaluation was performed with an average of 29 months, with a minimum of 12 months. The average active forward flexion was 103 degrees, the average of external rotation was 10 degrees and the average internal rotation reached the L4 spinous process. Two patients (66%) was able to perform the daily activities (Fig. 3).
The UCLA index was different for the three patients. One patient presented UCLA 14 (bad), another one presented UCLA 28 (regular) and the other patient UCLA 30 (good).
It was shown, by post-operative physical examination, the emergence of transient neuropraxia of Axillary Nerve in one patient (33%) that was solved at the end of 60 days.

Discussion
Chronic dislocation of the scapular-humeral joint is a difficult condition to be handled because of structural damage to the joint anatomy caused by the anomalous position of the humeral head [1-5, 12, 14]. The elapsed time since the trauma seems to increase the destruction of bone and capsuloligamentar tissue by compression and traction respectively[3,4, 12, 14]. The literature is controversial and shows intervals ranging from 24 hours to 45 days after injury to consider a CSD[7-9]. Having in mind that the elapsed time since the trauma makes the changes of capsuloligamentar tissue and bone, less and less reversible. It is known that primary soft tissue healing is as long as than 21 days, in average[15]. Thus the author will consider chronic dislocations those presenting the timeframe higher than 21 days. In our study, the most recent dislocation was 4 months.
The CSD is classified according to the direction in anterior and posterior and it is considered as type 2 Walch Fracture-Sequela Classification[6]. All patients included in the study had anterior CSD, which is less tolerated by the non-functional position of the upper limb[1] and the compression of the brachial plexus by the proximal humerus[16].
The bone and capsuloligamentous changes are generally definitive, irreversible and determine a poor prognosis of treatment[5,12,14,17,18]. Therapeutic options are resection arthroplasty (Jones Surgery)[19]; surgical reduction with the attempt to repair the rotator cuff or greater tuberosity fixation [20,21]; surgical reduction with reconstruction of soft tissue and bone, association or not of grafts; infra-spinatus’ Ramplissage [22,23,24]; surgical reduction followed by coracoid transfer to the anterior glenoid[5]; partial and total arthroplasties[4,25,26] and the simple observation of the evolution of the patient (supervised neglect)[17].
Metha[27] evaluated a case of CSD with six weeks of evolution that underwent surgical reduction and reconstruction of the humeral head with osteochondral graft. The case had a satisfactory outcome.
Li et al[5], evaluated the capacity of Latarjet procedure to keep the reduction in 35 patients with CSD. The dislocation recurrence rate was approximately 50%. Abdelhady[24] analyzed a series of four patients with CSD which held surgical reduction and Ramplissage of infra-spinatus in the Hill-Sacks defect. It was reported that one case (25%), with deficiency of the anterior glenoid bone stock, required a Latarjet as an additional procedure.
Venkatachalam et al[25] reported a case of CSD in a young patient (58 years) where an anatomical hemi-arthroplasty was held as well as bone reconstruction and biological resurfacing of the glenoid with enhanced anterior capsule allograft. They reported satisfactory outcomes for the procedure.
Rassi et al[28] reported a case of a 22-year-old bench press athlete with bilateral CSD who refused surgical treatment and had no pain and his arc of movement was considered functional with evolution.
Treatment of CSD has worsened its prognosis when it involves patients with advanced age, where the healing capacity and adaptation of soft tissue is compromised. These patients usually have poor rotator cuffs, therefore it is not possible to guarantee function when one choses to use the conventional shoulder prosthesis[17,26].
The literature is also controversial when analyzing the CSD in patients with advanced age. Galano et al[29] reported a more than 70-year-old patient with 15 days of shoulder dislocation submitted to closed reduction of the joint and arthroscopic suture of the rotator cuff. Yu et al[20] evaluated the surgical reduction of the CSD in seven patients with an average age of 74 years. Patients achieved improved active forward flexion without redislocation.
Jong-Hun Ji et al[14], reported a case of a 68-year-old patient presenting 4 months of CSD and rotator cuff injury that underwent a successful RSA.
Raiss et al[30], in a multi-center study, evaluated the largest series of cases in the literature. They studied the results of 22 CSD with average age of 71 years treated with RSA. They found an improvement in the Constant score, improvement on range of motion in flexion and external rotation. The range of motion achieved in this study was similar to that achieved in our patients. Another similarity factor of our series was the complication rate around 30%. They concluded that the RSA may be indicated in elderly patients with CSD and that bone deficiency In the glenoid is a poor prognostic factor.
The Reverse Shoulder Arthroplasty have had their indications extended in order to try to solve several serious joint disorders[13,14,30,31]. Its self stabilization’s characteristic may decrease the chances of redislocation, presented in other types of treatment for the CSD. The shoulder function can be satisfactorily restored through this procedure in patients who present missing damaged or insufficient rotator cuff, [30]. Kurowicki et al.[32[ analyzed a serie of 24 patients with an average age of 76 years, with severe anterior shoulder instability and glenoid bone loss that evolved into RSA. They observed that patients’ pain was mitigated and functions were improved after RSA. They also noted that this type of indication to RSA results in less arc of forward flexion then the classical indication for cuff arthropathy. Lower functional score rates and higher incidence of acromion fractures was found as well.
The initial assessment of the patient with CSD in general shows no neurological damage[17,18]. In our cases, the neurovascular examination was normal at the time of hospital admission for surgery.
The alcohol addiction predisposes the patient to falls and convulsive states, increasing the likelihood of shoulder dislocation[1,32,33]. Checchia et al.[4] showed an incidence of 23% of alcoholism among patients with CSD in their study. Habermayer et al.[26] did not show alcohol consumption as a factor related to dislocation in their 12 patients with CSD. Two of our patients were alcoholics (66%), therefore, we consider important to mention alcoholism as a variable in the study because they are patients with limited commitment to the physiotherapy postoperative program.
We consider bias in our study the limited number of cases, although it is a rare disease.

Conclusion
The characteristic of self stabilization of the Reverse Shoulder Arthroplasty can lead to medium-term satisfactory results for Chronic Shoulder Dislocations in elderly patients.

References

1 – Veado MAC. Luxação Inveterada do Ombro. Rev. Bras. Ortop;39(1/2):1-13, JAN-FEB 2004.
2 – De Palma A.F. Dislocations of the Shoulder, In Surgery of the Shoulder, 3rd ed., Philadelphia, J.B. Lippincott, 1973. p.461-474.
3 -Kirtland S, Resnick D, Sartoris DJ, Pate D, Greenway G. Chronic unreduced dislocation of the glenohumeral joint: imaging strategy and pathologic correlation. J Trauma. 1988 Dec;28(12):1622-31
4 – Checchia Sl, Doneux P, Miyazaki An, Bauer G, Akkari M & E, Acero J. Luxação anterior inveterada de ombro. Resultados obtidos no tratamento cirúrgico. Rev Bras Ortop;31(8):663-669,August 1996.
5 – Li Y, Jiang C. The Effectiveness of the Latarjet Procedure in Patients with Chronic Locked Anterior Shoulder Dislocation: A Retrospective Study. J Bone Joint Surg Am. 2016 May 18;98(10):813-23.
6 – Boileau P, Chuinard C, Le Huec JC, Walch G, Trojani C. Proximal humerus fracture sequelae: impact of a new radiographic classification on arthroplasty. Clin Orthop Relat Res. 2006 Jan;442:121-30.
7 – Schultz TJ, Jacobs B. & Patterson RL. Unrecognized dislocations of the shoulder. J Trauma 9: 1009-1023, 1969.
8 – Rowe C, Zarins B. Chronic unreduced dislocations of the shoulder. J Bone Joint Surg [Am] 64: 494-505, 1982.
9 – Postacchini F, Facchini M. The treatment of unreduced dislocation of the shoulder. A review of 12 cases. J Orthop Traumatol 13: 15-26, 1987.
10 – Deliz ED, Flatow EL. Chronic unreduced shoulder dislocations. In: Bigliani L.U.: Complications of shoulder surgery. Maryland, Williams and Wilkins, p. 127-138, 1993.
11 – Loebenberg MI, Cuomo F. The treatment of chronic anterior and posterior dislocations of the glenohumeral joint and associated articular surface defects. Orthop Clin North Am 31: 23-34, 2000.
12 – Sahajpal DT, Zuckerman JD. Chronic glenohumeral dislocation. J Am Acad Orthop Surg 2008; 16 : 385-398.
13 – Urch E, Dines JS, Dines DM. Emerging Indications for Reverse Shoulder Arthroplasty. Instr Course Lect. 2016;65:157-69.
14 – Ji JH, Shafi M, Jeong JJ, Ha JY. Case Report: Reverse total shoulder arthroplasty in the treatment of chronic anterior fracture dislocation complicated by a chronic full thickness retracted rotator cuff tear in an elderly patient. J Orthop Sci. 2016 Mar;21(2):237-40.
15 – Beredjiklian PK. Biologic Aspects of Flexor Tendon Laceration and Repair. J Bone Joint Surg Am, 2003 Mar;85(3):539-550.
16 – Cutts S, Prempeh M, Drew S. Anterior shoulder dislocation. Ann R Coll Surg Engl. 2009;91(1):2-7.
17 – Verhaegen F, Smets I, Bosquet M, Brys P, Debeer P. Chronic anterior shoulder dislocation: aspects of current management and potential complications. Acta Orthop Belg. 2012 Jun;78(3):291-5.
18 – Babalola OR, Vrgoč G, Idowu O, Sindik J, Čoklo M, Marinović M, Bakota B. Chronic unreduced shoulder dislocations: Experience in a developing country trauma centre. Injury. 2015 Nov;46 Suppl 6:S100-2.
19 – Rispoli DM, Sperling JW, Athwal GS, Schleck CD, Cofield RH. Pain relief and functional results after resection arthroplasty of the shoulder. J Bone Joint Surg 2007; 89-B : 1184-1187.
20 – Yu D, Xiao H, Shi W, Ju J. Effectiveness Of Surgical Treatment For Senile Chronic Shoulder Dislocation. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2015 Sep;29(9):1076-9.
21 – Kubiak G, Fabiś J. Clinical improvement after 2 years one stage bilateral open reduction of chronic anterior shoulderdislocations with internal fixation of greater tuberosity fractures. Case study. Ortop Traumatol Rehabil. 2013 Mar-Apr;15(2):175-81.
22. Diklic ID, Ganic ZD, Blagojevic ZD, Nho SJ, Romeo AA. Treatment of locked chronic posterior dislocation of the shoulder by reconstruction of the defect in the humeral head with an allograft. J Bone Joint Surg Br. 2010 Jan;92(1):71-6.
23 – Rouhani A, Navali A. Treatment of chronic anterior shoulder dislocation by open reduction and simultaneous Bankart lesion repair. Sports Med Arthrosc Rehabil Ther Technol. 2010 Jun 16;2:15. doi: 10.1186/1758-2555-2-15.
24 – Abdelhady AM. Neglected anterior shoulder dislocation: open remplissage of the Hill-Sachs lesion with the infraspinatus tendon. Acta Orthop Belg. 2010 Apr;76(2):162-5.
25 – Venkatachalam S, Nicolas AP, Liow R. Treatment of chronic anterior locked glenohumeral dislocation with hemiarthroplasty. Shoulder Elbow. 2014 Apr;6(2):100-4.
26 – Gavriilidis I, Magosch P, Lichtenberg S, Habermeyer P, Kircher J. Chronic locked posterior shoulder dislocation with severe head involvement. Int Orthop. 2010;34(1):79-84.
27 – Mehta V. Humeral head plasty for a chronic locked anterior shoulder dislocation. Orthopedics. 2009 Jan;32(1):52.
28 – El Rassi G, Hijjawi A, Matta J, Fahs S, Khair OA. Bilateral locked anterior shoulder dislocation in a bench-pressing athlete: case report. Arch Orthop Trauma Surg. 2015 Jun;135(6):747-9.
29 – Galano GJ, Dieter AA, Moradi NE, Ahmad CS. Arthroscopic management of a chronic primary anterior shoulder dislocation. Am J Orthop (Belle Mead NJ). 2010 Jul;39(7):351-5.
30 – Raiss P, Edwards TB, Bruckner T, Loew M, Zeifang F, Walch G. Reverse arthroplasty for patients with chronic locked dislocation of the shoulder (type 2 fracture sequela). J Shoulder Elbow Surg. 2016 Aug 10. pii: S1058-2746(16)30183-5.
31 – Motta Filho G, Galvão MV, Monteiro M, Cohen M, Brandão B. Registro das Artroplastias do Ombro. Rev. Bras Ortop. 2009;44(2):125-33.
32 – Kurowicki J, Triplet JJ, Momoh E, Moor MA, Levy JC. Reverse shoulder prosthesis in the treatment of locked anterior shoulders: a comparison with classic reverse shoulder indications. J Shoulder Elbow Surg. 2016 Jul 12. pii: S1058-2746(16)30108-2.
33 – Robinson CM, Aderinto J. Posterior shoulder dislocations and fracture-dislocations. J Bone Joint Surg Am. 2005;87(3):639-50.

How to Cite this article:Almeida AD, Zampieri R, Guarise da Silva P, Couto de Almeida N, Agostini AP. The use of Reverse Shoulder Arthroplasty for treatment of Chronic Shoulder Dislocations Acta of Shoulder and Elbow Surgery Jan – June 2017;2(1):11-14

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

January 10, 2017/0 Comments/in Vol 2| Issue 1| Jan-June 2017 /by ASESADMIN2016

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
Email: jose.cjunior@hsl.org.br

Abstract

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.

Introduction

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.

Methods
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.

Results
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

Discussion
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.

Conclusion
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.

References

1. Neviaser RJ. Lesions of the biceps and tendonitis of the shoulder. Orthop Clin North Am 1980;11:343-348.
2. Verma NN, Drakos M, O’Brien SJ. Arthroscopic transfer of the long head biceps to the conjoint tendon. Arthroscopy 2005;21(6):764.
3. Guelich DR, Lintner D. Arthroscopic Intraosseous Biceps Tenodesis. Oper Tech Sports Med 2007;15(1): 16-19 .
4. Abrams JS. Arthroscopic Biceps Tenodesis: Direct Suturing and Results. Oper Tech Sports Med 2007;15(1);10-15.
5. Gill TJ, McIrvin E, Mair SD, Hawkins RJ. Results of biceps tenotomy for treatment of pathology of the long head of the biceps brachii. J Shoulder Elbow Surg 2001;10:247-249.
6. Huffman GR, Wolf EM. Arthroscopic biceps tenotomy: Results in patients with symptomatic degeneration of the long head of the biceps brachii tendon. Arthroscopy 2003;19:5(suppl 2).
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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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The use of Reverse Shoulder Arthroplasty for treatment of Chronic Shoulder Dislocations

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

The use of Reverse Shoulder Arthroplasty for treatment of Chronic Shoulder Dislocations

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

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The use of Reverse Shoulder Arthroplasty for treatment of Chronic Shoulder Dislocations

Authors: Alexandre de Almeida [1], Rodrigo Zampieri [1], Pedro Guarise da Silva [1], Nayvaldo Couto de Almeida [1], Ana Paula Agostin [2]

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

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

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