The long head of biceps and associated tendinopathy.

This paper describes the current views on the pathology of lesions of the tendon of the long head of biceps and their management. Their diagnosis is described and their surgical management classified, with details of the techniques employed.

[Entrapment of the long head of the biceps: the "hourglass biceps". Another cause of pain and locking of the shoulder]. / Le long biceps en sablier ou long biceps piégé: une autre cause de douleur et de blocage de l'épaule.

PURPOSE OF THE STUDY: We describe a mechanical condition affecting the long head of the biceps tendon (LHBT) causing potentially unrecognized entrapment within the joint and subsequent pain and locking. This is caused by a hypertrophic intra-articular portion of the tendon that is unable to slide into the bicipital groove during elevation of the arm. MATERIALS AND METHODS: Twenty one patients were identified, during open (14 cases) or arthroscopic (7 cases) surgery, with a so called "hourglass biceps" i.e., hypertrophic intraarticular portion of the LHBT and incarceration of the tendon during elevation. All cases occurred in conjunction with a rotator cuff rupture except one who had a partial deep tear. All patients were treated by excision of the biceps, after tenodesis or bipolar tenotomy, and appropriate treatment of the concomitant lesions. RESULTS: All patients presented with anterior shoulder pain and loss of passive elevation averaging 10-20 degrees. A dynamic intraoperative test involving forward elevation with the elbow extended demonstrated entrapment of the tendon within the joint in each case. This test creates a characteristic "buckling" of the tendon and "squeezing" of the tendon between the humeral head and the glenoid ("hourglass test"). Excision of the tendon allowed immediate restoration of complete elevation. Mean Constant score increased from 38 points to 76 points postoperatively. DISCUSSION: The "hourglass biceps" is caused by a hypertrophic intraarticular portion of the tendon that is unable to slide into the bicipital groove during elevation of the arm. Loss of 10-20 degrees of passive elevation, bicipital groove tenderness, and radiographic findings of a hypertrophied tendon can aid in diagnosis. The "hourglass biceps" should not be misdiagnosed for a frozen shoulder. Definitive diagnosis is made at surgery with the "hourglass test": incarceration and squeezing of the tendon within the joint during forward elevation of the arm with the elbow extended. Simple tenotomy cannot resolve this mechanical block. Either tenotomy with excision of the intraarticular portion of the LHBT or tenodesis must be performed. The "Hourglass" biceps is an addition to the familiar pathologies of the long head of the biceps tendon (tenosynovitis, prerupture, rupture, instability), and should be considered in any case of chronic anterior shoulder pain associated with a loss of shoulder elevation.

Pacemaker placement and shoulder surgery: is there a risk?

INTRODUCTION: Surgery to the anterior aspect of the shoulder is performed by many surgical specialties but the techniques used by our cardiology colleagues for insertion of cardiac pacemaker wires are often not appreciated by the surgical community. The deltopectoral approach has been used for open pacemaker wire insertion for many years by cardiologists. METHODS: We surveyed a group of subspecialty shoulder surgeons as well as orthopaedic trainees to see if this approach for pacemakers is well recognised. We tried to assess what level of knowledge exists regarding pacemaker placement in general as well as specific risks. RESULTS: There appears to be a paucity of knowledge regarding pacemaker placement and related patient safety issues in both surveyed groups. There was no difference between the two groups, suggesting that the level of knowledge does not increase with experience and specialisation. CONCLUSIONS: There is the potential to cause harm to patients if the insertion site and type of device is not identified before commencing surgery in this region and steps must be taken to minimise any intra-operative risk. There is a risk from direct injury to the pacemaker and/or leads as well as the hazards of using diathermy in close proximity to a pacemaker. There must be more widespread dissemination of this information in order to minimise risks to patients with pacemakers in situ.

Dynamic ultrasound assessment in the diagnosis of intra-articular entrapment of the biceps tendon (hourglass biceps): A preliminary investigation.

BACKGROUND: The hourglass biceps, an intra-articular entrapment of the long head of the biceps (LHB), is a possible diagnosis in cases of shoulder pain associated with loss of passive elevation. PURPOSE: The objective of this study is to investigate the role of dynamic ultrasound (U/S) in determining the diagnosis of the hourglass biceps lesion. MATERIALS AND METHODS: A prospective cohort of 16 patients with the clinical suspicion of an hourglass lesion, a preoperative ultrasound, and a confirmed hourglass LHB at surgery, were included in the study. Eight patients had preoperative dynamic ultrasound assessment of the LHB, and eight had standard ultrasound investigations and served as a control group. RESULTS: Dynamic ultrasound accurately diagnosed an hourglass biceps in three out of eight cases. LHB hypertrophy was demonstrated in five out of eight cases with U/S and three out of eight cases with standard U/S. All patients were treated by excision of the intra-articular portion of the LHB, 15 by bipolar tenotomy, and one by LHB tenodesis. CONCLUSIONS: Dynamic ultrasound shows promise in improving the accuracy in diagnosis of LHB hypertrophy and the Hourglass lesion. LEVEL OF EVIDENCE: III (Consecutive case-control study investigating a diagnostic test).

Patterns of articular wear in the cadaveric elbow joint.

Thirty-two fixed cadaveric elbow specimens from an elderly population were examined photographically after staining of the articular cartilage. The photographic images of the articular wear areas observed were calibrated and superimposed to determine the overall pattern of articular wear in the elbow. In this group, the radiohumeral compartment showed the most frequent degenerative changes. A pattern of involvement could have been identified, proceeding from the posteromedial region of the radial head and the apex of the capitellum. Eventually, the entire lateral compartment is involved, but in most specimens examined the ulnohumeral and radioulnar articulations are preserved.

Medium-term dexa analysis of an uncemented femoral component.

We investigated the bone remodelling around the AML uncemented femoral component using DEXA analysis and plain radiography in 19 patients at a mean of 89 months from operation. All patients had previously been analysed at a mean of 32 months after surgery. We found a decrease in bone mineral density around the AML implant between the two scans in Gruen zones 1,2 and 6 of up to 8%, but an increase in zones 4,5 and 7 of up to 36%. The increase in zones 4 and 5 were statistically significant (P>0.05). The relative difference between the operated and unoperated hips also showed a reduction in the bone density ratio with time, except in zones 4 and 5 where an increase was seen. We confirm the results of previous studies of proximal stress shielding and distal loading around the AML implant and demonstrate that bone remodelling continues in the medium term. (Hip International 2004; 14: 182-8).