Case Study

A Variety of procedures have been explained and presented in surgical treatment of ruptured long head of biceps (proximal attachment) none of them are superior to each other . Here, is an effort  to tenodesis the ruptured long head of biceps with  a technique which combines transosseous fixation and interference fixation with cortical screws. Which is biomechanicaly stable ,better strength and cost effective.

A 45 year old patient presented with swelling and weakness in the right arm diagnosed as an ruptured long head of biceps (proximal attachment) treated with bone tunnelling and cortical screw fixation with 4.5 mm screw.

This procedure seems to be biomechanically stable , better strength and cost effective

Long head of biceps, tenodesis, bone tunnelling , 4.5 mm cortical screws.

A 45 yr old male patient presented with swelling in the right arm with weakness of elbow flexion since 1 month (fig 1).History of fall 1 month back on outstretched hand noticed pain & weakness while lifting heavy weights after the injury which caused, no history of decreased range of movement.
On examination no local rise of temperature, no other similar swellings noted in the body . Swelling was soft in consistency, smooth surface, and mobile. Skin over the swelling was normal with no neurological deficits. Tenderness was present on the acromioclavicular joint and at the bulge in the arm and popeye sign was present(Fig 1 &2).
Plain radiograph of arm AP and Lateral shows no bony deformity. MRI  shows full thickness tear in the long head of biceps with proximal part in the intraarticular and distal into the groove.
On shoulder arthroscopy, proximal attachment of long head of biceps was seen which was frayed and distal fragment was not visible

Considering the mri finding that the part of the tendon was intraarticular ,  diagnostic scopy was done intrarticular  origin of the biceps long head was found to be frayed and was debrided.
Subacromial scopy did not show the free edge of the tendon. The groove was explored with a needling technique but didn’t yield the tendon.
Further we explored the subpectoral region, the tendon was found encased in a sheath , crumpled up. this sign were the tendon is curled up could be called “fetal sign”.   The sheath was opened and the tendon edge was extracted, which stretched out to its length. The tendon edge was prepared similar to acl graft preparation using a whip stitch  technique using  fibre wire no.1. (arthrex)
The site of tenodesis was identified 2.5 cms below the pectoralis major insertion and the tendon was cut 1 cm distal to the tenodesis site so that 1 cm could be taken intraosseous.
Next, we made a bicortical drill hole of size 3.2 mm at the proposed tenodesis site , one side of the near cortex was purposely widened to accommodate the tendon as well as the interference screw.
1 cm proximal to the above said bicortical drill hole we made another unicortical drill hole of 2.5 mm drill . using a curved suture passer we shuttled the fibrewire strands through the distal hole and out of the proximal hole, thereby pulling the tendon into the medullary cavity .
A 4.5mm cortical screw with spiked washer was used for interference fit along side the tendon in the distal hole. The fibre wire strands were passed around the conical washer and the screw head and tied.
The elbow was put through the range of movement and integrity of the tenodesis was checked.
A wound was closed in layers.

Discussion:
Origin of long head of biceps is from supraglenoid tubercle of the scapula with an intra-articular portion that passes over the humeral head before exiting the glenohumeral joint through the bicipital groove^.1,2  The tendon is approximately 5 to 6 mm in diameter and approximately 9 cm in length. The size of the tendon varies, and the intra-articular portion is typically wide and flat whereas the extra-articular portion is both rounder and smaller³ .  LHB  rupture is one of the cause shoulder pain and weakness in the elbow flexion . Etiology for rupture of LHB may be trauma, overuse, senile degenerative, corticosteroid injections.
The most common sites of tendon rupture are at the tendon’s origin and at the exit of the bicipital groove near the musculotendinous junction.²⁸
Although many surgical procedures has been explained a decade none of them are superior to each other. Tenodesis of the LHB may be performed arthroscopically or in an open manner, either above the bicipital groove or through a subpectoral approach. Fixation techniques include suture anchor fixation, suture–to– adjacent tissue fixation, keyhole-to-bone fixation, and interference screw fixation.61-69
In all these procedures, the strength of fixation is very important. The ideal fixation method should allow early and active full range of motion.
This may be necessary for an athlete or an older patient because even a short period of immobilization may result in debilitating shoulder stiffness. In particular, athletes must be able to return to their sport as quickly and as fully functional as possible.
OZLAY ET AL
The strongest construct was made with the interference screw technique, followed by the tunnel, anchor, and keyhole techniques. There were no statistically significant differences
between the interference screw and tunnel techniques with respect to maximum load or deflection at maximum load.  of interference screws with suture anchors. Biomechanical studies investigating suture The load to failure for interference screw fixation is greater than that seen with suture anchors, as can easily be seen In a comparison of biomechanical anchor fixation have found a wide range of load to failure characteristics. Biomechanical failure ranged from 70 to 180 N with the most common cause of failure being suture failure at the eyelet.
So we decided to use combination of transosseous and interference fixation technique to treat the biceps rupture. Our, patient is a daily wage heavy worker now at the end of 1 year follow up he’s able to lift 5kg weight, do all day today activities. Here is an effort to light on view about to change the treatment of biceps rupture.