Variations of the intra-articular portion of the long head of the biceps tendon: A classification of embryologically explained variations

doi:10.1016/j.jse.2009.03.006

Journal of Shoulder and Elbow Surgery

Volume 18, Issue 4, July–August 2009, Pages 556-565

https://doi.org/10.1016/j.jse.2009.03.006 Get rights and content

Background

Although the intra-articular portion of the long head of the biceps (LHB) usually runs free, different types of fusions with the inferior surface of the capsule are known to be possible. Anatomic variations of this part of the LHB have been previously described and were nearly always considered to be innocent.

Materials and methods

Out of 2 populations of 1500 arthroscopies each, we collected prospectively and retrospectively all possible variations of the proximal portion of the LHB.

Results

We included 57 cases (1.91%) of this total population in an attempt to describe the complete range of these form variants: the simple vinculum or pulley-like sling, the partial or complete mesotenon between biceps and capsule, the complete adherent LHB, the double-tendon origin, the reversed-type split-tendon, and the complete absence of the LHB. We suggest a classification of 12 variations of the intra-articular portion of the LHB.

Discussion

By taking into account an extensive literature review, we suggest that these conditions are congenital and consider them as a result of partial detachment from the mesothelial or synovial fusion with the inferior surface of the capsule. The incidence of these variants and their associated pathologies are investigated.

Conclusion

By offering this new classification and a physiopathologic hypothesis, we try to explain why some of these anatomic variants may also acquire a pathologic significance.

Section snippets

Materials and methods

Ethical Committee approval was not required for this study because this was a literature review of embryology studies and a retrospective review of 3000 previous cases. No biopsies or special procedures were performed or needed for this study.

Between 1996 and 2006, the first Belgian author (C.D.) conducted 1476 shoulder arthroscopies for a wide variety of shoulder conditions. Between 2003 and 2006, the last Italian author (A.C.) also conducted about 1500 arthroscopies. The first author

Results

Together we collected 57 cases, 30 from the Belgian population and 27 in the Italian population, of which 33 (57.9%) were women and 24 (42.1%) were men. The average age was 41.7 years at time of surgery (range, 14-76 years). All 57 cases, or 1.91% of a total of 2976 shoulder arthroscopies, are included in an attempt to describe the complete range of these form variants, from simple vinculum (MESO-VI) to the completely adherent (ADH-CO) to the complete absence (ABC) of the LHB (Table I).

After

Discussion

The intra-articular portion of the biceps tendon has been the subject of an old debate about its embryology, anatomic origin, position, and variations. The early anatomic “in cadavera studies” paid great attention to the possible variations of the intra-articular course of the LHB. In a comparative anatomic study in 1878, Welcker²⁶ demonstrated that in certain mammals such as the horse and the tapir, the biceps runs completely extra-articular, superior, and separated by a bursa from the SSP

Acknowledgments

We thank Prof. Dr. Van Glabbeek Francis (University Hospital Antwerp) for his advice and contribution in sharing the very old manuscripts from his private library.

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The biceps brachii (BB) muscle is a two-headed muscle of the arm composed of one long head (LH) and one short head (SH). Accessory heads have been described and classified; however, reports of three concurrent accessory heads are especially rare, and their structural and functional analyses still require investigation. This study aims to analyze the structural and functional properties of a bilateral case of BB muscles each with three accessory heads.
A case of bilateral BB muscles with three accessory heads were discovered during routine human cadaver dissection. The muscles were carefully cleaned of extraneous tissue and photographed in situ. All five heads were examined bilaterally for gross structural features, and sarcomere states were examined via light microscopy. Maximal isometric force (F_max) and contralateral comparability (δ) were calculated for each head.
The three accessory heads originated sequentially from the mid-shaft of the humerus. The proximal accessory head inserted into the distal end of the SH, while the middle and distal accessory heads inserted separately into the adjoined LH and SH muscle mass just before the common tendon. All accessory heads were structurally similar (δ ≤ 0.17; mass = 2.10 g; length = 10.33 cm; PCSA = 0.23 cm²; F_max = 5.24 N) and were innervated by the musculocutaneous nerve. The left and right LH and SH collectively generated a F_max of 49.91 N and 53.05 N while the left and right accessory heads collectively generated a F_max of 18.04 N and 13.38 N, respectively.
The bilateral BB muscles with their accessory heads generated an almost equivalent total F_max (67.95 N vs. 66.43 N, respectively), ∼23.35% of which was generated by the accessory heads. Despite the conceivable advantage the accessory heads may offer to generating additional force, accessory muscles can also cause serious clinical implications. The gross imaging, biomechanical analyses, contralateral comparability data, and relevant clinical insights presented in this study may help guide diagnosis and treatment in related clinical cases.
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The long head of the biceps tendon (LHBT) has different properties and characteristics that render it a valuable tool in the hands of shoulder surgeons. Its accessibility, biomechanical strength, regenerative capabilities, and biocompatibility allow it to be a valuable autologous graft for repairing and augmenting ligamentous and muscular structures in the glenohumeral joint.
Numerous applications of the LHBT have been described in the shoulder surgery literature, including augmentation of posterior-superior rotator cuff repair, augmentation of subscapularis peel repair, dynamic anterior stabilization, anterior capsule reconstruction, post-stroke stabilization, and superior capsular reconstruction. Some of these applications have been described meticulously in technical notes and case reports, whereas others may require additional research to confirm clinical benefit and efficacy.
This review examines the role of the LHBT as a source of local autograft, with biological and biomechanical properties, in aiding outcomes of complex primary and revision shoulder surgery procedures.
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Tenodesis of the long head of the biceps tendon can be performed through arthroscopic and open techniques with various fixation methods and at different locations on the humerus. Many techniques have been described, with controversy surrounding the advantages and disadvantages of each. In this Technical Note, we describe an all-arthroscopic, intra-articular, single-portal, suprapectoral biceps tenodesis with an all-suture anchor. This technique also allows for suture passage through the biceps tendon before tenotomy to ensure proper maintenance of the length–tension relationship of the biceps musculotendinous unit.
A new significance of an old structure: Aponeurotic expansion of supraspinatus tendon and its relationships with biceps brachii long head and rotator cuff tendons
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In accordance with earlier reports, we observed this structure in three different morphological patterns based on its shape and size but our results demonstrated an incidence of about 20 %, lower than 50 % as previously reported [3]. Different etiologies are known to play part in LHB disorders, variations of the tendon itself being one of them [11,12]. Some authors argue that an accessory biceps tendon described by some researchers [8] is actually the very same entity with what Brodie and Clark et al. had described as aponeurotic expansion of supraspinatus tendon [1,2,13].
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A total of 82 male and 72 female cases with a mean age of 34 (±8.2) were included. Aponeurotic expansion could be identified in 31 cases (19.8 %). MRI findings for LHB disorders in this group was significantly higher (p = 0.01). The adjusted odds ratio of having LHB tendinopathy in the presence of aponeurotic expansion was 3.25 (% 95 CI:1.29−8.19). No significant correlation was found between presence of aponeurotic expansion and subscapularis or supraspinatus tendon disorders (p = 0.66 and p = 0.792 respectively). Age was a significant variable for disorders of all three tendons (p < 0.001).
On 3.0 T MRI, findings of LHB tendon disorders were significantly more common in cases with aponeurotic expansion of supraspinatus tendon. This anatomical variation may have an unrecognized clinical significance.
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However, the increased use of shoulder arthroscopy has revealed a greater number of anatomical variations of the LHBT, ranging from 1.9 to 7.4% (Dierickx et al., 2009; Kanatli et al., 2011). The LHBT anatomical variations in adults have been classified by Dierickx et al. (2009), based on the anatomy of the LHBT and its dynamic behaviour during arthroscopy. Dierickx et al. classified the LHBT anomalies under four categories: partial or complete mesotenon, full adhesion capsular, split and absence.
The anatomical variations of the proximal portion of the long head of the biceps brachii tendon (LHBT) are rarely observed in clinical practice. However, an increase in the rate of shoulder arthroscopic surgery has led to an increase in the observation of anatomical variations of this region. The aim of this work was to analyze the development of the LHBT in 23 human embryos ranging from the 6th to 8th weeks of development. The LHBT develops from the glenohumeral interzonal mesenchyme in the 6th week. By week 7, the myotendinous junction of the LHBT develops. The anlage of the LHBT is separated from that of the glenohumeral capsule during week 8. Our results suggest that the most important period for the LHBT development occurs between the 6th and 8th weeks of embryonic development. Alterations during this critical period may cause anatomical variations of the LHBT. An additional case report from our own experience is provided as Supplementary material.
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The intra-articular course of the long head of the biceps tendon (LHBT) through the glenohumeral joint is a special anatomical feature. It originates at the supraglenoid tubercle with fibers deriving directly from the glenoid labrum and is stabilized by a pulley complex at the entrance into the bicipital groove. The LHBT is biomechanically important for the glenohumeral joint and is considered as dynamic stabilizer that acts in synergy with other structures like the rotator cuff. The characteristic anterior shoulder pain of LHBT pathology can be caused by chronic inflammation, ruptures, instability, or by a combination of these. Due to its anatomical and biomechanical interaction with other structures, isolated lesions of the LHBT are extremely rare. Rotator cuff tears are highly associated with pathology of the LHBT. The complexity of LHBT lesions represents a major challenge for the clinician regarding both diagnosis and treatment.

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ShoulderVariations of the intra-articular portion of the long head of the biceps tendon: A classification of embryologically explained variations

Background

Materials and methods

Results

Discussion

Conclusion

Section snippets

Materials and methods

Results

Discussion

Acknowledgments

Arthoscopy

Arthoscopy

Arthroscopy

Arthroscopy

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

Developmental morphological and histological studies on structures of the human fetal shoulder joint

Cells Tissues Organs

Extraarticular variants of the long head of the biceps brachii: a reminder of embryology

J Shoulder Elbow Surg

Anomaly of the long tendon of the biceps muscle of the arm

NY Med Rec

Surgery of the shoulder

Bifurcate origin of the long head of the biceps tendon

Arthroscopy

Congenital absence of the long head of the biceps tendon. A case report

J Bone Joint Surg Am

Shoulder
Variations of the intra-articular portion of the long head of the biceps tendon: A classification of embryologically explained variations