Our Technique in Replacement Labral Defect by Using Biceps Tendon

Yousef Khair¹*, Ahmad Al Zoubi MD ², Ehab Azam MD³, Mutaz Qasaimeh MD⁴

1,2,3,4. Orthopedic Department - King Hussein Medical Center Amman-Jordan.

*Correspondence to: Yousef Khair, Orthopedic Department - King Hussein Medical Center Amman-Jordan.

Copyright

© 2023 Yousef Khair. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 08 June 2023

Published: 01 July 2023

Abstract

One of the most common orthopedic pathologies that face the orthopedic surgeons is anterior recurrent shoulder, which may cause either due to trauma or recurrent abduction and external rotation. Shoulder stability depends on the labrum which is responsible for deepening of the glenoid. There are many techniques to manage anterior recurrent shoulder dislocation either through open or arthroscopic technique. Arthroscopic Bankart repair is the most popular method used to obtain shoulder stability. Using Biceps tendon as autograt is a new technique to replace the labral defect in the patients have unreconstable labrum, the purpose of this study to eplain this technique.

Methods: 36 patients with history of recurrent anterior shoulder dislocation involved in this study presented to our clinic at the orthopedic department in King Hussein Medical Center between January 2018 to October 2023. All the patients were evaluated clinically, they had a positive apprehension and relocation tests, and radiologically by asking for X-ray, MRI. A questioner American Shoulder and Elbow Surgeons (ASES) and Disabilities of Arm, Shoulder and Hand (DASH) scores to evaluate the activities of the patient’s pre-operation and post-operation. The average age for the patients 36 years (range 17-55 years), the average follow-up period was 21 months (range 6 – 36 months).

Results: After the mean time of follow up 21 months all the patients have a negative apprehension and relocation tests, they have a free pain full range of motion. American Shoulder and Elbow Surgeons score pre- operation was (40%-58%) and post-operation (85%-95%), while Disabilities of Arm, Shoulder and Hand score pre-operation was (26.8% – 29.5%) and post-operation (4.2% – 5%). All the shoulder scores improved significantly (p< 0.05).

Conclusion: Biceps autograft to replace the labral defect considers a good option to restore shoulder stability by gaining the bumper effect as it deepening the glenoid, it reduces the need for other procedures such as Latarjet and it reduces the rate of anterior shoulder dislocation. On other hand it has less side effect.

Keywords:  Recurrent anterior shoulder dislocation, Bankart repair, Biceps tendon autograft, Latarjet procedure.

Introduction

Injury of the labrum is a common cause for recurrent anterior shoulder dislocation as labrum deepened 50% of glenoid, repetitive abduction with external rotation and trauma which causing labral injury is the main cause of shoulder dislocation [1]. The patients who are between 16-28 are more likely to shoulder dislocation with high prevalence of recurrence and shorter interval between the first episode of shoulder dislocation and recurrent instability [2]. Patients with shoulder dislocation is divided into three groups according to Walch, those who have a shoulder dislocation that reduced by another person is classified as group 1, group 2 those with shoulder subluxation (the shoulder is not completely dislocated), while group 3 those who have painful shoulder due to instability of the shoulder which confirmed by physical examination [3].

Outcome of management of shoulder dislocation and its difficulties due to capsuloligamentous and labral defect keened in many studies [4]. The main cause of shoulder dislocation is Bankart lesion which can be treated by arthroscopic Bankart repair by using anchors. Patients with labral tear or glenoid bone loss more than 25% have a high recurrence rate [5], Repairing the bankart lesion and capsule stretching is very important to gain stable shoulder in patients who complained of recurrent shoulder dislocation.

According to cadaveric studies 19% to 21% of glenoid defect may only need a soft tissue repair while when there is more than 25% of glenoid defect Latarjet contemplates a good solution to manage anterior recurrent shoulder dislocation [6,7].

Since 2018 we started to use our new technique which we described it by using the biceps tendon as autograft to replace the labral and glenoid defect which will restore the glenohumeral joint in those patients who complain of recurrent anterior shoulder dislocation.

The purpose of this study to explain our technique by using biceps tendon as a graft to replace the labral defect and its outcome.

Methods

36 patients with history of recurrent anterior shoulder dislocation involved in this study presented to our clinic at the orthopedic department in King Hussein Medical Center between January 2018 to October 2023. All the patients were evaluated clinically, they had a positive apprehension and relocation tests [8]. Patients who have a neurological or muscular abnormality were excluded from this study while patients have a Rotator cuff tear were included in this study. Patients also were evaluated radiologically by asking for X-ray AP view, internal and external views, axillary view, CT scan for any bony pathology such as bony Bankart and MRI to confirm the labral defect and if it is associated with another pathology (Figure1). A questioner American Shoulder and Elbow Surgeons (ASES) and Disabilities of Arm, Shoulder and Hand (DASH) scores to evaluate the activities of the patient’s pre-operation and post-operation. The average age for the patients 36 years (range 17-55 years), the average follow-up period was 21 months (range 6 – 36 months). During the period of follow up there is no patient presented with history of shoulder dislocation post operation. All the patients who underwent this technique had unrepairable labral defect.

Surgical Technique

The technique is performed by the main author, after either general anesthesia or regional block the patient is positioned in lateral position, the arm is retracted by a traction sleeve in 70 degrees abduction and 10-degree forward flexion. Two portals were used the posterior portal and the anterior superior portal using outside-in technique. Diagnostic evaluation for the shoulder joint and the labrum, we identified the situation of the labrum if it can’t be repaired, we decided to use the biceps tendon as graft to replace the labral defect (figure2). The shaver is used to prepare the glenoid. A double loaded suture anchor is inserted at the inferior part of glenoid at 5 o’clock for the Right shoulder and 7 o’clock for the left shoulder 2 to 2 mm from the glenoid rim. The suture passer is inserted through the Biceps tendon (figure3), then the shuttle or PDS suture is retrieved from the anterior portal and loaded with one of the anchor sutures and then the free part of the shuttle or PDS is retrieved the loaded suture, a similar step is done for the inferior part of the capsule. The radiofrequency is used for tenotomy of the most proximal part of biceps tendon. A simple stitch is done, and knot technique is performed depend on the surgeon preference this will approximate the proximal part of the Biceps tendon to the inferior part of the capsule (figure4).

Then the suture passer (spectrum) is passed either from the capsule and under the Biceps tendon or directly pass under the Biceps tendon and then the PDS is retrieved with the second suture and the knot is performed. The same steps are performed for the second and third anchors. The patient’s arm is held by the arm sling and abduction pillow 30 degrees.

Results

After the mean time of follow up 21 months all the patients have a negative apprehension and relocation tests, they have a free pain full range of motion. American Shoulder and Elbow Surgeons score pre- operation was (40%-58%) and post-operation (85%-95%), while Disabilities of Arm, Shoulder and Hand score pre-operation was (26.8% – 29.5%) and post-operation (4.2% – 5%). All the shoulder scores improved significantly (p< 0.05).

Discussion

Recurrent anterior shoulder dislocation may affect hard worker and athletes, most of the cases were treated surgically either by arthroscopy or open. Injury which caused capsulo-labral detachment can be managed by arthroscopy. Latarjet is a procedure to restore the shoulder stability when there is bone loss in the glenoid rim by the sling effect of the conjoint tendon [9]. Patients with poor soft tissue, glenoid rim erosion or high impacted athletes have a high recurrence rate which reached up to 37% [10,11]. According to many studies which show that there are several risk factors which considered as a reason for high rate of failure in professional players who need forceful external rotation and abduction, younger age and those with soft tissue and bone defects [12,13]. Soft tissues procedure has a less complication than transfer the coracoid process to glenoid as nonunion [14], graft resorption [15,16] and graft migration [14], also destroying the coracoacromial arch which cause superior instability [17,18].

There is study which suggest transfer of the long Biceps tendon to the anterior border of the glenoid cavity through the subscapular tendon, this will reproduce a tensile effect, create an anterior barrier and increase the labral surface through augmentation with the tendon [19,20,21,22,23]. Another study which used the Biceps tendon as a sling to augment the shoulder in the anterior inferior angel of the glenoid by creating a tunnel in the glenoid and fixation of the Biceps tendon inside the tunnel [24].

In our technique Using Biceps tendon as autograft to cover the labral defect will do the same work of the labrum to form a bumper by deepening the socket so the ball will be in its place, for this reason we repair the capsule and the Biceps tendon to restore shoulder instability with less side effects when comparing with conjoined tendon transfer and it is a simple procedure.

Conclusion

Biceps tendon when it is used as a graft to replace the labral defect will work as the same way of the labrum by deepening of the glenoid this will make the head of the humerus in its place, the labrum will be as a pumper. This technique will restore the shoulder instability with less complication and a significant result comparing with Latarjet procedure, in addition it is a simple procedure. The patients who underwent this techniquehad a significant improvement in ASES and DASH scores, with pain-free full range of motion and negative apprehension and relocation tests post operative.

References

1. Dodson CC, Cordasco FA. Anterior glenohumeral joint dislocations. Orthop Clin North Am. 2008;39:507–518, vii.[PubMed] [Google Scholar].

2. Rhee YG, Cho NS, Cho SH. Traumatic anterior dislocation of the shoulder: factors affecting the progress of the traumatic anterior dislocation. Clin Orthop Surg. 2009;1:188–193. [PMC free article][PubMed] [Google Scholar]

3. Walch G (1991) The anterior recurrent dislocation of the shoulder. Rev ChirOrthop 77: 177-192.

4. Gartsman G, Roddey TS, Hammerman S Arthroscopic treatment of anterior-inferior glenohumeral instability: two to five-year follow-up J Bone Joint Surg, 82 (7) (2000), pp. 991-1003 PMID: 10901314 DOI: 10.2106/00004623-200007000-00011.

5. De Wilde LF, Berghs BM, Audenaert E, Sys G, Van Maele GO, et al. (2004) About the variability of the shape of the glenoid cavity. Surg Radiol Anat 26(1): 54-59.

6. Itoi E, Lee SB, Berglund LJ, Berge LL, An KN (2000) The effect of a glenoid defect on anteroinferior stability of the shoulder after Bankart repair: A cadaveric study. J Bone Joint Surg Am 82(1): 35-46.

7. Latarjet M (1954) Treatment of recurrent dislocation of the shoulder. Lyon Chir 49: 994-997.

8. Nakagawa S, Yoneda M, Hayashida K, Obata M, Fukushima S, et al. (2005) Forced shoulder abduction and elbow flexion test: A new simple clinical test to detect superior labral injury in the throwing shoulder. Arthroscopy 21(11): 1290-1295.

9. Dines JS, Dodson CC, McGarry MH, Oh JH, Altchek DW (2013) Contribution of osseous and muscular stabilizing effects with the Latarjet procedure for anterior instability without glenoid bone loss. J Shoulder Elbow Surg 22: 1689-1694.

10.Hovelius L, Korner L, Lundberg B, C Akermark, P Herberts, et al. (1983) The coracoid transfer for recurrent dislocation of the shoulder: technical aspects of the Bristow-Latarjet procedure. J Bone Joint Surg Am 65: 926- 934.
11. Hovelius L, Sandstro?m B, Olofsson A (2012) The effect of capsular repair, bone block healing, and position on the results of the Bristow-Latarjet procedure (Study III): long-term follow-up in 319 shoulders. J Shoulder Elbow Surg 21: 647-660.

12. Balg F, Boileau P (2007) The instability severity index score. A simple preoperative score to select patients for arthroscopic or open shoulder stabilization. J Bone Joint Surg Br 89: 1470-1477.

13. Cole BJ, Millett PJ, Romeo AA, Stephen SB, James RA, et al. (2004) Arthroscopic treatment of anterior glenohumeral instability: indications and techniques. Instr Course Lect p. 53: 545-558.

14.Boileau P, The?lu CE?, Mercier N, Xavier O, Robert HC, et al. (2014) Arthroscopic Bristow-Latarjet combined with Bankart repair restores shoulder stability in patients with glenoid bone loss. Clin Orthop Relat Res 472(8): 2413-2424.

15. Di Giacomo G, Costantini A, de Gasperis N, De Vita A, Bernard KHL, et al. (2011) Coracoid graft osteolysis after the Latarjet procedure for anteroinferior shoulder instability: a computed tomography scan study of twenty-six patients. J Shoulder Elbow Surg 20(6) : 989-995.

16. Zhu YM, Jiang CY, Lu Y (2015) Coracoid bone graft resorption after Latarjet procedure is underestimated: a new classification system and a clinical review with computed tomography evaluation. J Shoulder Elbow Surg 24(11): 1782-1788.

17. Lee TQ, Black AD, Tibone JE, McMahon PJ (2001) Release of the coracoacromial ligament can lead to glenohumeral laxity: a biomechanical study. J Shoulder Elbow Surg 10(1): 68-72.

18. Su WR, Budoff JE, Luo ZP (2009) The effect of coracoacromial ligament excision and acromioplasty on superior and anterosuperior glenohumeral stability. Arthroscopy 25: 13-18.

19.Karlsson J. In reparable rotator cuff tears with lesions of the long head of the biceps brachii tendon, tenotomy did not differ from tenodesis in terms of function or pain. J Bone Joint Surg Am. 2017;99(4):351.

20. Garcia Jr JC, Nunes CV, Raffaelli MP, Sasaki AD, Salem SH, Rowinski S, et al. Long head of biceps- a vestigial structure? Acta Shoulder Elbow Surg. 2017;2(1):22-7.

21. Taylor SA, Ramkumar PN, Fabricant PD, Dines JS, Gausden E, White A, et al. The clinical impact of bicipital tunnel decompression during long head of the bicep’s tendon surgery: a systematic review and meta-analysis. Arthroscopy. 2016;32(6):1155-64.

22. Winston BA, Robinson K, Crawford D. “Monocept”: a brief report of congenital absence of the long head of the Biceps tendon and literature review. Case Rep Orthop. 2017; 2017:1090245.

23. Surgical treatment of shoulder instability with trans-subscapularis transfer of the biceps long tendon. Max Roge?Rio FReitas RaMos1; YondeR aRchanjo ching san-ju?nioR2; Luiz henRique PeReiRa aLves3 DOI: 10.1590/0100-6991e-20192151.

24. Arthroscopic Transfer of the Long Head of the Biceps Brachii for Anterior Shoulder Instability Jin Tang, B.M.a and Jinzhong Zhao, M.D.b, ∗ 2017 Oct; 6(5): e1911–e1917 doi: 10.1016/j.eats.2017.07.009.