Arthroscopic Tenoplasty in Congenital Split Biceps Long Head

Abstract

The long head of the biceps brachii tendon arises mainly from the superior glenoid labrum and supraglenoid tubercle. Biceps brachii display anatomic variations, but these are rarely encountered. We report, for the first time, a technique called arthroscopic intra-articular biceps tenoplasty describing restoration of the long head of the biceps tendon using the superior capsule in a case of anomalous congenital split biceps tendon encountered incidentally during diagnostic glenohumeral arthroscopy in a patient who was treated for shoulder instability and SLAP tear.T he long head of the biceps tendon (LHBT) displays numerous anatomic variations, but their clinical relevance remains unclear.1 The knowledge of these variants may be relevant for both glenohumeral surgery and arthroscopy.2 The intra-articular bifurcate anomaly of the LHBT origin is relatively less frequent. This anomaly is usually undetectable on preoperative evaluations such as magnetic resonance imaging and ultrasound because of an interpretational difficulty and lack of preoperative insight toward the anomalous biceps long head. It usually can be found incidentally during arthroscopic procedures for other purposes. The LHBT functions as a humeral head depressor and a secondary restraint to anterior instability, particularly in the abducted and externally rotated position.3 By depressing the humeral head and elevating the glenoid labrum, the LHBT imparts dynamic stability to the glenohumeral joint. 4 Patients with this variation may have weakening of the rotator cuff. Recognition of abnormalities of the biceps tendon is important because they are a common source of shoulder pain both alone and in combination with abnormalities of the rotator cuff, labrum, and other structures.5 Preoperative awareness of the anomalous LHBT is important because it can be the etiologic basis of other structural injuries, such as rotator cuff tears and labral tears. Case Report and Operative TechniqueA 23-year-old right handedominant man presented with left shoulder pain and restriction of range of motion. He had a history of anterior shoulder dislocation from a fall onto the ground 3 months earlier, and the shoulder joint had subsequently dislocated 3 times.The clinical examination showed no tenderness along the route of the biceps tendon. Active range of motion was grossly restricted, with 90 of flexion, 80 of abduction, 20 of external rotation, and internal rotation to L5. The apprehension test, O'Brien test, crossarm sign, and Speed test were positive. There was no tenderness along the route of the LHBT.The initial radiograph showed no abnormal findings. A subsequent magnetic resonance arthrogram showed a SLAP lesion and anteroinferior labral tear. The LHBT was present in the bicipital groove. The rotator cuff was intact.Nonoperative management including oral analgesics and intra-articular or subacromial space steroids and local anesthetic injection had failed to alleviate the patient's symptoms. On the basis of the clinical findings and radiologic evidenc...