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Clin Shoulder Elb > Volume 27(2); 2024 > Article
Lee: Long head biceps tendon as a graft material
The long head tendon of the biceps brachii (LHBT) is an interesting anatomical structure. There have been numerous controversies regarding its role within the joint, its pathophysiology, and its influence on surrounding anatomical structures [1-5]. First, it is a common source of shoulder pain, especially when it is involved with rotator cuff pathology [6-8]. Approximately 70% of pathologic LHBTs are involved with rotator cuff tears [9-11]. In addition, with it being described as a sentinel sign, the relationship between the LHBT and subscapularis is well known [12-16]. Often, the instability of an LHBT is caused by a subscapularis tear, and kinking of displaced LHBTs may further deteriorate a torn subscapularis.
Another debate concerns its role within the glenohumeral joint. The LHBT has a role as a stabilizer of the humeral head, especially in an external rotation position. Meanwhile, numerous studies have revealed similar results between tenotomy and tenodesis of LHBTs, and these results have raised doubts on the actual role of the LHBT as a head stabilizer and the necessity of unconditional preservation of the LHBT by tenodesis. These points have contributed to the justification of prophylactic tenotomy as a means of eliminating pain, especially with age [17,18]. No definite deterioration of elbow function was exhibited with tenotomy, and cosmetic deformation was almost the only issue [6,17,19]. Since sacrifice of the LHBT is clinically acceptable and exhibited better results in the aspect of pain relief, clinical practice has begun to use the LHBT beyond simple tenotomy.
The first studies regarding the utilization of LHBT introduced the procedure as biceps augmentation for the treatment of large rotator cuff tear [20,21]. Tenotomized LHBT was interposed to bridge the gap in partial repair of massive rotator cuff tears, and this technique exhibited promising repair integrity. The subsequent clinical result by Park et al. [22] supported the clinical value of the augmentation technique . The next techniques that utilized LHBT for the treatment of large cuff tear were a biceps rerouting technique and anterior cable reconstruction [23-26]. Even though these techniques have similarities with utilizing LHBTs to supplement torn rotator cuffs that cannot be fully repaired, the concepts of the techniques are different from one another. While biceps augmentation focuses on the coverage of the footprint and bridging the gap, the main target of biceps rerouting is stabilizing the humeral head [27]. In addition, the technique of anterior cable reconstruction is very similar to that of biceps rerouting, but the focus is anatomical restoration of L-shaped tears of the supraspinatus rather than stability of the humeral head [28]. Despite the increasing number of cases utilizing LHBTs for the treatment of rotator cuff tears, detection of underlying LHBT pathology and lack of known prognostic factors remain as challenges. Stability of an LHBT cannot be guaranteed, especially with larger-sized cuff tears.
In this study, serum high-sensitivity C-reactive protein (hs-CRP) was proposed as a reliable predictor for pathologic LHBT. Specifically, hs-CRP higher than 1 mg/L reflected the presence of grade II LHBT tear and may aid surgeons in deciding whether certain LHBTs are suitable for in situ graft material. Serum hs-CRP is a biomarker of low-grade inflammation and is used to identify various cardiovascular and inflammatory processes in clinical care and epidemiologic studies. The biggest issue with this marker is its low specificity. Practically, hs-CRP is convenient as a screening device and as a reaction parameter of infective condition rather than as a diagnostic tool. Since the specificity is low, objectivity is insufficient to reflect the condition of a specific disease.
Since various repair options using the LHBT have recently been proposed along with the increase in clinical reports, it is important to accurately determine the condition of an LHBT before it is utilized as a graft. The authors have conducted various statistical analyses to increase the objectivity of the results and to reduce the risk of multicollinearity and heteroscedasticity. In addition, the objectivity of the result revealed with hs-CRP is supported by the significant association of other factors such as subscapularis tears, thyroid problems, or conditions of torn supraspinatus with LHBTs. However, we cannot overlook the importance of imaging modalities on interpreting the condition of LHBTs, especially in terms of diagnostic specificity. The validity of various imaging modalities and classifications has been verified and validated through several studies with high clinical reliability [29-31].
Constructional demolition of an LHBT used as a graft for a repaired rotator cuff can lead to worse results by affecting a relatively well-preserved partially repaired cuff tendon. Considering the lack of parameters that can reflect the preoperative conditions of LHBTs, the levels of preoperative hs-CRP that are capable of reflecting the condition of LHBTs would contribute to the surgeon’s decision on whether to utilize LHBTs with cuff repairs.

NOTES

Author contributions

Writing and approval of the final manuscript: HJL.

Conflict of interest

None.

Funding

None.

Data availability

None.

Acknowledgments

None.

REFERENCES

1. Itoi E, Motzkin NE, Morrey BF, An KN. Stabilizing function of the long head of the biceps in the hanging arm position. J Shoulder Elbow Surg 1994;3:135–42.
crossref pmid
2. Itoi E, Kuechle DK, Newman SR, Morrey BF, An KN. Stabilising function of the biceps in stable and unstable shoulders. J Bone Joint Surg Br 1993;75:546–50.
crossref pmid
3. Kim SH, Ha KI, Kim HS, Kim SW. Electromyographic activity of the biceps brachii muscle in shoulders with anterior instability. Arthroscopy 2001;17:864–8.
crossref pmid
4. Rodosky MW, Harner CD, Fu FH. The role of the long head of the biceps muscle and superior glenoid labrum in anterior stability of the shoulder. Am J Sports Med 1994;22:121–30.
crossref pmid
5. Yamaguchi K, Riew KD, Galatz LM, Syme JA, Neviaser RJ. Biceps activity during shoulder motion: an electromyographic analysis. Clin Orthop Relat Res 1997;(336):122–9.
crossref
6. Frost A, Zafar MS, Maffulli N. Tenotomy versus tenodesis in the management of pathologic lesions of the tendon of the long head of the biceps brachii. Am J Sports Med 2009;37:828–33.
crossref pmid
7. Hitchcock HH, Bechtol CO. Painful shoulder: observations on the role of the tendon of the long head of the biceps brachii in its causation. J Bone Joint Surg Am 1948;30A:263–73.
pmid
8. Nho SJ, Shindle MK, Sherman SL, Freedman KB, Lyman S, MacGillivray JD. Systematic review of arthroscopic rotator cuff repair and mini-open rotator cuff repair. J Bone Joint Surg Am 2007;89 Suppl 3:127–36.
crossref pmid
9. Chen CH, Hsu KY, Chen WJ, Shih CH. Incidence and severity of biceps long head tendon lesion in patients with complete rotator cuff tears. J Trauma 2005;58:1189–93.
crossref pmid
10. Murthi AM, Vosburgh CL, Neviaser TJ. The incidence of pathologic changes of the long head of the biceps tendon. J Shoulder Elbow Surg 2000;9:382–5.
crossref pmid
11. Beall DP, Williamson EE, Ly JQ, et al. Association of biceps tendon tears with rotator cuff abnormalities: degree of correlation with tears of the anterior and superior portions of the rotator cuff. AJR Am J Roentgenol 2003;180:633–9.
pmid
12. Walch G, Nové-Josserand L, Boileau P, Levigne C. Subluxations and dislocations of the tendon of the long head of the biceps. J Shoulder Elbow Surg 1998;7:100–8.
crossref pmid
13. Adams CR, Brady PC, Koo SS, et al. A systematic approach for diagnosing subscapularis tendon tears with preoperative magnetic resonance imaging scans. Arthroscopy 2012;28:1592–600.
crossref pmid
14. Adams CR, Schoolfield JD, Burkhart SS. Accuracy of preoperative magnetic resonance imaging in predicting a subscapularis tendon tear based on arthroscopy. Arthroscopy 2010;26:1427–33.
crossref pmid
15. Lafosse L, Reiland Y, Baier GP, Toussaint B, Jost B. Anterior and posterior instability of the long head of the biceps tendon in rotator cuff tears: a new classification based on arthroscopic observations. Arthroscopy 2007;23:73–80.
crossref pmid
16. Sahu D, Fullick R, Giannakos A, Lafosse L. Sentinel sign: a sign of biceps tendon which indicates the presence of subscapularis tendon rupture. Knee Surg Sports Traumatol Arthrosc 2016;24:3745–9.
crossref pmid
17. Lee HJ, Jeong JY, Kim CK, Kim YS. Surgical treatment of lesions of the long head of the biceps brachii tendon with rotator cuff tear: a prospective randomized clinical trial comparing the clinical results of tenotomy and tenodesis. J Shoulder Elbow Surg 2016;25:1107–14.
crossref pmid
18. Kelly AM, Drakos MC, Fealy S, Taylor SA, O’Brien SJ. Arthroscopic release of the long head of the biceps tendon: functional outcome and clinical results. Am J Sports Med 2005;33:208–13.
crossref pmid
19. Zhang Q, Zhou J, Ge H, Cheng B. Tenotomy or tenodesis for long head biceps lesions in shoulders with reparable rotator cuff tears: a prospective randomized trial. Knee Surg Sports Traumatol Arthrosc 2015;23:464–9.
crossref pmid
20. Cho NS, Yi JW, Rhee YG. Arthroscopic biceps augmentation for avoiding undue tension in repair of massive rotator cuff tears. Arthroscopy 2009;25:183–91.
crossref pmid
21. Rhee YG, Cho NS, Lim CT, Yi JW, Vishvanathan T. Bridging the gap in immobile massive rotator cuff tears: augmentation using the tenotomized biceps. Am J Sports Med 2008;36:1511–8.
crossref pmid
22. Park SR, Sun DH, Kim J, Lee HJ, Kim JB, Kim YS. Is augmentation with the long head of the biceps tendon helpful in arthroscopic treatment of irreparable rotator cuff tears. J Shoulder Elbow Surg 2018;27:1969–77.
crossref pmid
23. Kim JH, Lee HJ, Park TY, Lee JU, Kim YS. Preliminary outcomes of arthroscopic biceps rerouting for the treatment of large to massive rotator cuff tears. J Shoulder Elbow Surg 2021;30:1384–92.
crossref pmid
24. Kim YS, Lee HJ, Park I, Sung GY, Kim DJ, Kim JH. Arthroscopic in situ superior capsular reconstruction using the long head of the biceps tendon. Arthrosc Tech 2018;7:e97–103.
crossref pmid pmc
25. Park MC, Itami Y, Lin CC, et al. Anterior cable reconstruction using the proximal biceps tendon for large rotator cuff defects limits superior migration and subacromial contact without inhibiting range of motion: a biomechanical analysis. Arthroscopy 2018;34:2590–600.
crossref pmid
26. Chen RE, Bakhsh WR, Lipof JS, McVicker ZG, Voloshin I. Rotator cuff anterior cable reconstruction with long head of biceps tendon autograft. Arthrosc Tech 2020;9:e711–5.
crossref pmid pmc
27. Han SY, Lee TQ, Wright DJ, et al. Effect of biceps rerouting technique to restore glenohumeral joint stability for large irreparable rotator cuff tears: a cadaveric biomechanical study. J Shoulder Elbow Surg 2020;29:1425–34.
crossref pmid
28. Shin SJ, Kim IW, Park I, Lee S, Kim MS. Anterior cable reconstruction using the biceps tendon in retracted anterior l-shaped rotator cuff tears. Arthrosc Tech 2020;10:e55–60.
crossref pmid pmc
29. Bélanger V, Dupuis F, Leblond J, Roy JS. Accuracy of examination of the long head of the biceps tendon in the clinical setting: a systematic review. J Rehabil Med 2019;51:479–91.
crossref pmid
30. Kim JY, Rhee SM, Rhee YG. Accuracy of MRI in diagnosing intra-articular pathology of the long head of the biceps tendon: results with a large cohort of patients. BMC Musculoskelet Disord 2019;20:270.
crossref pmid pmc
31. Malavolta EA, Assunção JH, Guglielmetti CL, de Souza FF, Gracitelli ME, Ferreira Neto AA. Accuracy of preoperative MRI in the diagnosis of disorders of the long head of the biceps tendon. Eur J Radiol 2015;84:2250–4.
crossref pmid


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