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PURPOSE: The hamstrings muscles are innervated by sciatic nerve branches. However, previous studies assessing which and how many branches innervate each muscle have yielded discrepant results. This study investigated the innervation patterns of hamstrings. MATERIALS AND METHODS: Thirty-five cadaver limbs were investigated. The average age of subjects was 78.6 ± 17.2 years, with 48.6% male and 51.4% female, while 57.1% were right limbs and 42.9% left. The sciatic nerve, hamstrings and associated structures were dissected. The number of nerve branches for each muscle and the level where they penetrated the muscle were recorded. RESULTS: The sciatic nerve was connected by a fibrous band to the long head of the biceps femoris. This muscle was innervated by either one or two branches, which penetrated the muscle into its superior or middle third. The short head of the biceps femoris was innervated by a single nerve that usually penetrated its middle third, but sometimes inferiorly or, less commonly, superiorly. The semitendinosus was always innervated by two branches, the superior branch penetrating its upper third, the inferior mostly the middle third. The semimembranosus usually was innervated by a single nerve branch that penetrated the muscle at its middle or lower third. Four specimens revealed common nerves that innervated than one muscle. CONCLUSIONS: We have characterized hamstring innervation patterns, knowledge that is relevant to neurolysis, surgery of the thigh, and other procedures. Moreover, a mechanical connection between the sciatic nerve and biceps femoris long head was identified that could explain certain neuralgias.

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The distal rupture of the biceps brachii muscle tendon (DBT) accounts for 3% of biceps ruptures. Diagnosis typically relies on high clinical suspicion and complementary imaging studies, with >90% of cases documented in males between the fourth and sixth decades of life. Reports of DBT ruptures in females are scarce, mostly involving partial and degenerative injuries. Here, we present an unprecedented case of a 28-year-old female professional mixed martial arts athlete with a total traumatic DBT rupture. The athlete underwent surgical repair using anchor reattachment technique. No complications were observed, and the athlete showed satisfactory outcomes, being cleared for physiotherapy after 2 weeks and returning to sports after a 3-month postoperative period.

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PURPOSE: The biceps brachii muscle (BBM) is a large and thick muscle on the ventral portion of the upper arm. The scientific literature reports the existence of extra heads. OBJECTIVE: The present work investigated the frequency of occurrence of BBM accessory head(s) in four different Anatomy Laboratories at universities in Northeast Brazil. MATERIAL AND METHODS: Once the upper limbs with an anatomical variation of the BBM heads were identified, the accessory head was evaluated for morphometric characterization (the length, width, and thickness). RESULTS: The sample consisted of 249 upper limbs and the outcomes were 26 members with BBM accessory heads (10.44% of the total sample). Among the 26 members studied was found a single accessory head in 22 (84.62%), two accessory heads in 3 (11.54%), and three accessory heads in 1 (3.85%). BBMs with one, two, and three accessory heads were found, with different origins. The average length, width, and thickness of these accessory heads were 169.39mm, 10.25mm, and 3.39mm, respectively. CONCLUSION: The frequency of BBM accessory heads in a population of northeastern Brazil in this cadaveric study was 10.44%.

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PURPOSE: The purpose of this study is to compare the patient-reported outcomes and return to sports of the conservative and surgical treatment of distal hamstring tendon injuries. METHODS: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, two reviewers searched PubMed, Scopus and Virtual Health Library databases in January 2023. Clinical studies evaluating conservative or surgical management outcomes of distal hamstring tendon injuries were considered eligible for this systematic review if predefined criteria were fulfilled: (1) published in English or Spanish; (2) evaluated any of the following: patient-reported outcomes, return-to-sports rate (RTS-R) or return-to-sports time (RTS-T). Data were presented in tables using absolute values from individual studies and derived pooled percentages. RESULTS: Eighteen studies were included for 67 patients and 68 distal hamstring tendon injuries. Initially, 39 patients (58.2%) underwent surgical treatment, whereas 28 (41.8%) were treated conservatively. Among conservative treatment patients, 15 failed and had to be operated on (53.6%), all with distal semitendinosus tendon injuries. Anchor fixation was the technique of choice in 20 lesions (36.4%), tenodesis in 16 (29.1%), tenectomy in 14 (25.5%) and sutures were preferred in five (9%). Thirteen out of 28 patients (46.4%) undergoing initial conservative treatment returned to sports at a mean of 3.6 months (range 1 week to 12 months), in contrast to surgical treatment, in which 36 out of 39 patients (92.3%) returned at a mean of 4.2 months (range 6 weeks to 12 months). Additionally, 14 of 15 patients (93.3%) converted to surgical treatment after failed conservative treatment returned to sports at a mean of 7.6 months after injury. CONCLUSION: Initial surgical treatment of distal hamstring tendon injuries yields a high RTS-R (92.3%) at a mean of 4.2 months. Furthermore, 15 out of 28 patients (53.6%) initially treated conservatively had to be operated on, delaying the RTS-T (mean 7.6 months after injury) without affecting their RTS-R. LEVEL OF EVIDENCE: IV.

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BACKGROUND: Shoulder pain related to pathology of the long head of the biceps tendon (LHBT) can be debilitating. Chronic LHBT tendinopathy is a common condition that is difficult to treat. Little consensus exists regarding the optimal approach to treating individuals with LHBT tendinopathy. OBJECTIVE: To systematically scope the literature to identify and present the available information regarding physical therapist interventions used for the management of individuals with LHBT tendinopathy including types of interventions used or recommended. METHODS: A scoping review of physical therapist interventions used to treat LHBT was conducted of the CINAHL, Embase, Medline, and SportDiscus databases. Full text records reporting physical therapist-based interventions in individuals with proximal LHBT pathology were included. Articles not written in English were excluded. RESULTS: Of the 4059 records identified, 14 articles met the inclusion criteria. Interventions used to treat LHBT tendinopathy identified in quantitative studies included: extracorporeal shock wave therapy, polarized light, ultrasound, low-level laser, iontophoresis, general exercise, eccentric training, stretching, dry needling, and joint mobilization. Interventions described in literature reviews, clinical commentaries, and a Delphi study included: therapeutic modalities, manual therapy, exercise, dry needling, and patient education. CONCLUSION: This scoping review reported interventions primarily based on therapeutic modalities in quantitative studies while literature reviews, clinical commentaries, and a Delphi study described the addition of manual therapy, patient education, exercise, and dry needling. Overall, there is a dearth of evidence detailing the conservative management of LHBT tendinopathy.

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Resumen: Introducción: en el tratamiento de la patología del tendón de la cabeza larga del bíceps (TCLB) la tenodesis «relajada¼ es una tenodesis artroscópica suprapectoral alta, que busca disminuir la tensión del TCLB y, por tanto, el dolor persistente. Objetivo: evaluar resultados clínicos y radiológicos de la tenodesis «relajada¼ en una serie prospectiva de sujetos sometidos a compensación laboral. Material y métodos: cohorte prospectiva de 54 hombros con tenodesis «relajada¼ con tornillo interferencial intraarticular, mismo cirujano, Octubre de 2014 a 2018, centro de trauma nivel 1. Se analizaron datos demográficos, resultados clínicos, funcionales y radiográficos. A los seis meses se realizó una ecografía de control y se evaluaron complicaciones. Resultados: edad media 49 ± 9 años, seguimiento promedio 16 ± 4 meses. El diagnóstico primario fue rotura del manguito rotador en 79%, patología primaria del bíceps en 10% y otras patologías en 11%. Al término del seguimiento, la elevación anterior activa fue 157.7 ± 22.7, rotación externa 47 ± 16.6, rotación interna mediana T12, Constant Score 83 ± 12.05 puntos, valoración subjetiva del hombro 83 ± 12.97% y escala visual análoga del dolor 1.4 ± 1.7 puntos. Un paciente sufrió una rotura del bíceps y dos casos una asimetría estética del brazo. En ecografía, en 98% se visualizó el TCLB in situ y en 10% se objetivaron cambios inflamatorios en la corredera bicipital. Reportamos 21% de complicaciones. Conclusiones: la tenodesis «relajada¼ presenta resultados clínicos, funcionales e imagenológicos satisfactorios, con baja tasa de fallo.

Abstract: Introduction: in the treatment the long head of the biceps tendon (LHBT) pathology, the «relaxed tenodesis¼ is an arthroscopic articular suprapectoral tenodesis that seeks to lower the tension on the LHBT, and therefore, theoretically avoid persistent pain. Objective: to assess clinical and radiological results of «relaxed¼ tenodesis in a prospective cohort of patient with work related illness. Material and methods: prospective cohort, 54 shoulders with «relaxed¼ tenodesis performed with an intra-articular interference screw by the same surgeon, from October 2014 to 2018, in a level 1 trauma center. Demographic, clinical, functional and radiologic results were analyzed. On 6 months follow-up, a sonographic and clinical assessment was performed. Results: mean age 49 ± 9, mean follow-up 16 ± 4 months. The main diagnosis was a rotator cuff tear in 79%, primary biceps pathology in 10% and other pathologies in 11%. At the end of follow-up, the cohort showed active anterior elevation 157.7 ± 22.7, external rotation 47 ± 16.6, median internal rotation T12, Constant Score 83 ± 12.05 points, subjective shoulder value 83 ± 12.97% and pain visual analogue scale 1.4 ± 1.7 points. One patient had a biceps tear and two had cosmetic arm asymmetry. On ultrasound 98% had the LHBT in situ and 10% had inflammatory changes on the bicipital groove. There were complications in 21% of the sample. Conclusions: «relaxed biceps tenodesis¼ is a technique that shows good clinical, functional and sonographic results, with low failure rate.

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PURPOSE: Although the initial description of the distal biceps tendon (DBT) hook test (HT) reported 100% sensitivity (Sn) and specificity (Sp), subsequent retrospective series have demonstrated imperfect validity. The purpose of this investigation was to prospectively assess the validity and reliability of the HT for complete DBT ruptures. We aimed to determine the Sn/Sp and interrater reliability for the HT. METHODS: A consecutive series of adult patients presenting to our outpatient clinics with an elbow complaint was prospectively examined. Patients were included if they had undergone advanced imaging (magnetic resonance imaging or ultrasound) that imaged the DBT and underwent DBT repair. There were four participating surgeons, all of whom were blinded to magnetic resonance imaging/ultrasound prior to performing the HT. To determine the Sn/Sp of the HT and advanced imaging, intraoperative findings served as the primary reference standard. The interrater reliability of the HT was calculated for cases in which a primary examiner (surgeon) and secondary examiner (physician assistant or resident) performed the HT. RESULTS: Of 64 patients who had undergone advanced imaging, 28 (44%) underwent DBT surgery and were included in the assessment of Sn/Sp. The mean age was 49 years, and all patients were men. The Sn and Sp of the HT were 96% and 67%, respectively. Advanced imaging demonstrated 100% Sn and Sp. Twenty-five patients were evaluated by a primary and secondary examiner. The interrater reliability was substantial (Cohen kappa, 0.71). CONCLUSIONS: The Sn and Sp of the HT were 96% and 67%, respectively, when assessed prospectively. Advanced imaging findings (magnetic resonance imaging/ultrasound) demonstrated 100% Sn and Sp. The HT can be performed reliably by examiners with varying experience levels. Considering the imperfect validity of the HT, we caution against the use of this examination alone to diagnose DBT ruptures. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.

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Objective To translate and culturally adapt the Long Head of Biceps Tendon (LHB) score into Brazilian Portuguese. Methods The process involved translations by professionals fluent in the target language, followed by independent back translations. Next, a committee compared the original and translated versions, pretested the final version, and concluded it. Results We translated and adapted the questionnaire according to the proposed methodology. In the first version in Portuguese (VP1) there was divergence regarding the translation of twelve terms. Compared to the original version, the back translation of VP1 presented eight diverging terms. A committee prepared a second version in Portuguese (VP2) and applied it to a pretest group consisting of 30 participants. Finally, we conceived the third version in Portuguese, called LHB-pt. Conclusion The translation and cultural adaptation into Brazilian Portuguese of the LBH score was successfully accomplished.

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PURPOSE: This study aimed to quantify and assess perioperative costs in an integrated healthcare system for patients undergoing distal biceps tendon (DBT) repair with and without the use of postoperative bracing and formal physical (PT) or occupational (OT) therapy services. In addition, we aimed to define clinical outcomes after DBT repair using a brace-free, therapy-free protocol. METHODS: We retrospectively reviewed all cases of DBT repairs within our integrated system from 2015 to 2021. We performed a retrospective review of a series of DBT repairs utilizing the brace-free, therapy-free protocol. For patients with our integrated insurance plan, a cost analysis was conducted. Claims were subdivided to assess total charges, costs to the insurer, and patient costs. Three groups were created for comparisons of total costs: (1) patients who had both postoperative bracing and PT/OT, (2) patients who had either postoperative bracing or PT/OT, and (3) patients who had neither postoperative bracing nor PT/OT. RESULTS: A total of 36 patients had our institutional insurance plan and were included in the cost analysis. For patients using both bracing and PT/OT, these services contributed 12% and 8% of the total perioperative costs, respectively. Implant costs accounted for 28% of the overall cost. Forty-four patients were included in the retrospective review with a mean follow-up of 17 months. The overall QuickDASH was 12; two cases resulted in unresolved neuropraxia, and there were no cases of re-rupture, infection, or reoperation. CONCLUSIONS: Within an integrated healthcare system, postoperative bracing and PT/OT services increase the cost of care for DBT repair and account for 20% of the total perioperative charges in cases where bracing and therapy are used. Considering the results of prior investigations indicating that formal PT/OT and bracing offer no clinical advantages over immediate range of motion (ROM) and self-directed rehabilitation, upper-extremity surgeons should forego routine brace and PT/OT utilization after DBT repair. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

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Abstract Objective To translate and culturally adapt the Long Head of Biceps Tendon (LHB) score into Brazilian Portuguese. Methods The process involved translations by professionals fluent in the target language, followed by independent back translations. Next, a committee compared the original and translated versions, pretested the final version, and concluded it. Results We translated and adapted the questionnaire according to the proposed methodology. In the first version in Portuguese (VP1) there was divergence regarding the translation of twelve terms. Compared to the original version, the back translation of VP1 presented eight diverging terms. A committee prepared a second version in Portuguese (VP2) and applied it to a pretest group consisting of 30 participants. Finally, we conceived the third version in Portuguese, called LHB-pt. Conclusion The translation and cultural adaptation into Brazilian Portuguese of the LBH score was successfully accomplished.

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INTRODUCTION: in the treatment the long head of the biceps tendon (LHBT) pathology, the «relaxed tenodesis¼ is an arthroscopic articular suprapectoral tenodesis that seeks to lower the tension on the LHBT, and therefore, theoretically avoid persistent pain. OBJECTIVE: to assess clinical and radiological results of «relaxed¼ tenodesis in a prospective cohort of patient with work related illness. MATERIAL AND METHODS: prospective cohort, 54 shoulders with «relaxed¼ tenodesis performed with an intra-articular interference screw by the same surgeon, from October 2014 to 2018, in a level 1 trauma center. Demographic, clinical, functional and radiologic results were analyzed. On 6 months follow-up, a sonographic and clinical assessment was performed. RESULTS: mean age 49 ± 9, mean follow-up 16 ± 4 months. The main diagnosis was a rotator cuff tear in 79%, primary biceps pathology in 10% and other pathologies in 11%. At the end of follow-up, the cohort showed active anterior elevation 157.7 ± 22.7, external rotation 47 ± 16.6, median internal rotation T12, Constant Score 83 ± 12.05 points, subjective shoulder value 83 ± 12.97% and pain visual analogue scale 1.4 ± 1.7 points. One patient had a biceps tear and two had cosmetic arm asymmetry. On ultrasound 98% had the LHBT in situ and 10% had inflammatory changes on the bicipital groove. There were complications in 21% of the sample. CONCLUSIONS: «relaxed biceps tenodesis¼ is a technique that shows good clinical, functional and sonographic results, with low failure rate.

INTRODUCCIÓN: en el tratamiento de la patología del tendón de la cabeza larga del bíceps (TCLB) la tenodesis «relajada¼ es una tenodesis artroscópica suprapectoral alta, que busca disminuir la tensión del TCLB y, por tanto, el dolor persistente. OBJETIVO: evaluar resultados clínicos y radiológicos de la tenodesis «relajada¼ en una serie prospectiva de sujetos sometidos a compensación laboral. MATERIAL Y MÉTODOS: cohorte prospectiva de 54 hombros con tenodesis «relajada¼ con tornillo interferencial intraarticular, mismo cirujano, Octubre de 2014 a 2018, centro de trauma nivel 1. Se analizaron datos demográficos, resultados clínicos, funcionales y radiográficos. A los seis meses se realizó una ecografía de control y se evaluaron complicaciones. RESULTADOS: edad media 49 ± 9 años, seguimiento promedio 16 ± 4 meses. El diagnóstico primario fue rotura del manguito rotador en 79%, patología primaria del bíceps en 10% y otras patologías en 11%. Al término del seguimiento, la elevación anterior activa fue 157.7 ± 22.7, rotación externa 47 ± 16.6, rotación interna mediana T12, Constant Score 83 ± 12.05 puntos, valoración subjetiva del hombro 83 ± 12.97% y escala visual análoga del dolor 1.4 ± 1.7 puntos. Un paciente sufrió una rotura del bíceps y dos casos una asimetría estética del brazo. En ecografía, en 98% se visualizó el TCLB in situ y en 10% se objetivaron cambios inflamatorios en la corredera bicipital. Reportamos 21% de complicaciones. CONCLUSIONES: la tenodesis «relajada¼ presenta resultados clínicos, funcionales e imagenológicos satisfactorios, con baja tasa de fallo.

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Purpose: As many as one-third of patients with heart failure secondary to systemic, wild-type transthyretin amyloidosis have an associated distal biceps tendon (DBT) rupture. Our purpose was to identify the prevalence of amyloid deposition in patients undergoing operative repair of acute traumatic DBT ruptures. Methods: In this prospective investigation, a consecutive series of patients who underwent repair of an acute traumatic DBT rupture underwent a tendon biopsy to assess for amyloid deposition. All specimens were viewed under gross microscopy by a board-certified pathologist. For initial screening, either Congo red or Thioflavin-T immunohistochemistry analysis was conducted to determine amyloid status. If staining was positive for amyloid deposition using either technique, the tissue sample was sent to an outside facility for specific amyloid protein identification through liquid chromatography-tandem mass spectrometry. Baseline demographics were also recorded for each patient. Results: A total of 30 patients who underwent biopsy and repair of an acute DBT rupture were included. The mean age was 48 years, and all patients were men. Seven (23%) patients had a history of carpal tunnel syndrome, and 1 (3%) patient had evidence of heart failure at the time of surgery. One (3%) patient had evidence of amyloid deposition in the DBT, which was confirmed using liquid chromatography-tandem mass spectrometry. Conclusions: Although one-third of patients with heart failure secondary to cardiac amyloidosis have an associated DBT rupture, younger patients with acute traumatic DBT ruptures do not appear to be uniquely at risk for amyloid deposition at the time of DBT repair. Larger registry studies may be necessary to define the risk of developing cardiac amyloidosis years after sustaining an acute DBT rupture. Type of study/level of evidence: Prognostic IV.

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Objectives The capsuloligamentous structures of the shoulder work as static stabilizers, together with the biceps and rotator cuff muscles, increasing the contact surface of the glenoid cavity. Free nerve endings and mechanoreceptors have been identified in the shoulder; however, there are a few studies that describe the presence of these nerves in the biceps' insertion. The present study aimed to describe the morphology and distribution of nerve endings using immunofluorescence with protein gene product 9.5 (PGP 9.5) and confocal microscopy. Methods Six labrum-biceps complexes from six fresh-frozen cadavers were studied. The specimens were coronally cut and prepared using the immunofluorescence technique. In both hematoxylin and eosin (H&E) and immunofluorescence, the organization of the connective tissue with parallel collagen fibers was described. Results In the H&E study, vascular structures and some nerve structures were visualized, which were identified by the elongated presence of the nerve cell. All specimens analyzed with immunofluorescence and confocal microscopy demonstrated poor occurrence of morphotypes of sensory corpuscles and free nerve endings. We identified free nerve endings located in the labrum and in the bicipital insertion, and sparse nerve endings along the tendon. Corpuscular endings with fusiform, cuneiform, and oval aspect were identified in the tendon. Conclusion These findings support the hypothesis that the generation of pain in the superior labral tear from Anterior to posterior (SLAP) lesions derives from the more proximal part of the long biceps cord and even more from the upper labrum. Future quantitative studies with a larger number of specimens may provide more information on these sensory systems.

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Abstract Objectives The capsuloligamentous structures of the shoulder work as static stabilizers, together with the biceps and rotator cuff muscles, increasing the contact surface of the glenoid cavity. Free nerve endings and mechanoreceptors have been identified in the shoulder; however, there are a few studies that describe the presence of these nerves in the biceps' insertion. The present study aimed to describe the morphology and distribution of nerve endings using immunofluorescence with protein gene product 9.5 (PGP 9.5) and confocal microscopy. Methods Six labrum-biceps complexes from six fresh-frozen cadavers were studied. The specimens were coronally cut and prepared using the immunofluorescence technique. In both hematoxylin and eosin (H&E) and immunofluorescence, the organization of the connective tissue with parallel collagen fibers was described. Results In the H&E study, vascular structures and some nerve structures were visualized, which were identified by the elongated presence of the nerve cell. All specimens analyzed with immunofluorescence and confocal microscopy demonstrated poor occurrence of morphotypes of sensory corpuscles and free nerve endings. We identified free nerve endings located in the labrum and in the bicipital insertion, and sparse nerve endings along the tendon. Corpuscular endings with fusiform, cuneiform, and oval aspect were identified in the tendon. Conclusion These findings support the hypothesis that the generation of pain in the superior labral tear from Anterior to posterior (SLAP) lesions derives from the more proximal part of the long biceps cord and even more from the upper labrum. Future quantitative studies with a larger number of specimens may provide more information on these sensory systems.

Resumo Objetivos As estruturas capsulo-ligamentares do ombro funcionam como estabilizadores estáticos, juntamente com os músculos do bíceps e do manguito rotador, aumentando a superfície de contato da cavidade glenoide. Terminações nervosas livres e mecanorreceptores foram identificados no ombro; no entanto, existem alguns estudos que descrevem a presença desses nervos na inserção do bíceps. Este estudo teve como objetivo descrever a morfologia e distribuição de terminações nervosas utilizando imunofluorescência com protein gene product 9.5 (PGP 9.5) e microscopia confocal. Métodos Foram estudados seis complexos labrum-bíceps de seis cadáveres congelados frescos. Os espécimes foram cortados coronalmente e preparados pelo método de imunofluorescência. Tanto em hematoxilina e eosina (H&E) quanto em imunofluorescência, foi descrita a organização do tecido conjuntivo com fibras paralelas de colágeno. Resultados No estudo de H&E, foram visualizadas estruturas vasculares e algumas estruturas nervosas, que foram identificadas pela presença alongada da célula nervosa. Todas as amostras analisadas com imunofluorescência e microscopia confocal demonstraram baixa ocorrência de morfotipos de corpúsculos sensoriais e terminações nervosas livres. Identificamos terminações nervosas livres localizadas no labrum, inserção bicipital e terminações nervosas esparsas ao longo do tendão. Terminais corpusculares com aspecto fusiforme, cuneiforme e oval foram identificados no tendão. Conclusão Esses achados corroboram a hipótese de que a geração de dor nas lesões labrais superiores de anterior a posterior (SLAP, na sigla em inglês) deriva da parte mais proximal do cabo longo do bíceps e ainda mais do labrum superior. Estudos quantitativos futuros com um número maior de espécimes podem fornecer mais informações sobre esses sistemas sensoriais.

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BACKGROUND: Massive rotator cuff tears have a high incidence of postoperative retear that can reach 90%. It is still unclear which intervention may reduce the incidence of retear and improve the functional and clinical outcomes. PURPOSE/HYPOTHESIS: The purpose of this study was to investigate the clinical and structural outcomes at 2 years after repair of reparable massive rotator cuff tears with and without the use of partial superior capsular reconstruction (pSCR), using the autologous long head of the biceps tendon (LHBT) as a graft. It was hypothesized that augmentation with a pSCR would decrease retear rates. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: The authors compared arthroscopic repair of massive posterosuperior rotator cuff tears with and without augmentation using the LHBT for pSCR between 2015 and 2017. After applying the selection criteria, 106 patients were included in the study and distributed into 2 groups of 50 and 56 patients. Patients in the first group (50 patients) underwent arthroscopic repair without use of the LHBT (AR group), and patients in the second group (56 patients) underwent arthroscopic repair with use of the LHBT for pSCR (AR-LHBT group). The structural outcome was evaluated by ultrasound at 2 years of follow-up. Function and pain were evaluated preoperatively and at the 2-year follow-up using the American Shoulder and Elbow Surgeons (ASES) score and visual analog scale (VAS). Pre- and postoperative active range of motion, including forward elevation, external rotation, and abduction, were also documented. RESULTS: No significant differences were found between groups regarding the baseline characteristics. After 24 months, both groups showed significant improvement from preoperative ASES scores, VAS score, and active range of motion (P < .01 for all). Patients in the AR-LHBT group showed significant improvements in postoperative functional and pain scores compared with the AR group in all measurements at the 2-year follow-up (ASES score: 77.23 ± 7.45 vs 71.04 ± 9.28, P < .01; VAS score: 1.64 ± 1.03 vs 2.12 ± 1.06, P < .01). Final range of motion was significantly increased for the AR-LHBT group for forward elevation (155 [interquartile range {IQR}, 150-160] vs 150 [IQR, 140-170]; P < .01) and abduction (150 [IQR, 140-157.5] vs 120 [IQR, 100-140]; P < .01), but external rotation was significantly greater for the AR group (54.43 ± 10.55 vs 59.5 ± 10.55; P < .01). Postoperative ultrasonography at the 2-year follow-up revealed a higher retear rate in the AR group than in the AR-LHBT group (46% vs 14%; P < .01). CONCLUSION: Use of the LHBT for pSCR to augment massive rotator cuff tears resulted in markedly lower retear rates and modestly improved pain and function outcomes compared with repair alone.

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BACKGROUND: Shear wave elastography technique estimates biological tissue shear elastic modulus (µ[kPa]), which can be used as an objective, muscle-specific indicator of stiffness increase caused by spasticity. We measured both the brachioradialis and biceps brachialis µ in hemiparetic post-stroke patients (n = 11). The spastic arm was compared with the supposedly non-affected contralateral limb and correlated with Fugl-Meyer Assessment and Modified Ashworth Scales. METHODS: Shear elastic modulus was estimated using an Aixplorer V.9 ultrasound device with the elbow at full extension. Average shear elastic modulus t-test, effect sizes, correlation matrix, spider plots and factor analysis were used to check for differences between spastic and nonspastic sides and explore relationships among the variables. FINDINGS: Spastic brachioradialis µ (22.54 ± 11.59 kPa) and biceps brachialis (26.86 ± 12.07 kPa) were significantly greater than the non-spastic counterparts (13.13 ± 2.81 kPa, p = 0.031, ηp2 = 0.3846 for brachioradialis and 15.25 ± 5.00 kPa, p = 0.007, ηp2 = 0.5345 for biceps brachialis). Significant correlations were observed between the spastic brachioradialis and biceps µ and Modified Ashworth Scales, but no correlation with Fugl-Meyer Assessment. INTERPRETATION: Elastography can provide muscle-specific shear elastic modulus estimations of spastic brachioradialis and biceps brachialis, which are distinct from the nonspastic side. In some patients, there was no clear correspondence of the Fugl-Meyer Assessment functional scale with Modified Ashworth Scales and µ, suggesting that spasticity is not the only determinant of arm function. Additionally, shear wave elastography of brachioradialis and biceps brachialis muscles may guide the spasticity treatment, for instance, selecting the preferable candidate for botulinum toxin therapy.

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Resumen: Introducción: La lesión del tendón distal del bíceps se presenta comúnmente en pacientes masculinos entre la quinta y sexta década de la vida. El mecanismo de la lesión es una contracción excéntrica con el codo en flexión de 90o. Para su tratamiento quirúrgico, en la literatura se describen varias opciones con diferentes abordajes, tipo de sutura a utilizar y diversos métodos de fijación de la reparación del tendón distal de bíceps. Las manifestaciones clínicas musculoesqueléticas del COVID-19 son fatiga, mialgia, artralgia, pero los efectos musculoesqueléticos del COVID-19 continúan siendo poco claros. Caso clínico: Paciente masculino de 46 años, COVID-19 positivo, con una lesión aguda del tendón distal del bíceps y secundaria a un trauma mínimo, sin otros factores de riesgo. El paciente fue tratado quirúrgicamente siguiendo las guías ortopédicas y de seguridad para el paciente y el personal médico debido a la pandemia COVID-19. El procedimiento quirúrgico de la técnica de double tension slide (DTS) con una sola incisión es una opción confiable y en nuestro caso de una baja morbilidad, con pocas complicaciones y una buena opción cosmética. Conclusión: El manejo de patologías ortopédicas en pacientes COVID-19 positivos va en aumento, así como las implicaciones éticas y ortopédicas del manejo de estas lesiones y/o el retraso de su atención durante la pandemia.

Abstract: Introduction: Distal biceps tendon injury commonly occurs in male patients between the fifth and sixth decade of life. The mechanism of the injury is an eccentric contraction with the elbow in flexion of 90 degrees. For its surgical treatment, several options have been described in the literature with different approaches, type of suture to be used and various methods of fixing the repair of the distal biceps tendon. The musculoskeletal clinical manifestations of COVID-19 are fatigue, myalgia, arthralgia, but the musculoskeletal effects of COVID-19 remain unclear. Case report: 46-year-old COVID-19 positive male patient with acute distal biceps tendon injury and secondary to minimal trauma, with no other risk factors. The patient was treated surgically following orthopedic and safety guidelines for the patient and medical staff due to the COVID-19 pandemic. The surgical procedure of the double tension slide (DTS) technique with a single incision in a reliable option and our case of a low morbidity, few complications and a good cosmetic option. Conclusion: The management of orthopedic pathologies in COVID-19 positive patients is increasing as well as the ethical and orthopedic implications of the management of these injuries and/or the delay of their care during the pandemic.

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SUMMARY: Anatomic variation of the biceps brachii muscle (BBM) is frequently observed; its pattern is diverse and clinically important. During the educational dissection of a 78-year-old Korean male cadaver, six additional asymmetrical heads of the biceps brachii muscle (BBM) were found on both sides. On the right side, two additional heads originated from the humerus; the musculocutaneous nerve passed between these heads and the short head of the BBM. Four additional heads were found on the left side, anterior to the BBM, one of which originated from the pectoralis major muscle. Posterior to the BBM, two heads of tendons originated from the coracobrachialis muscle and one head of the muscle belly originated from the humerus. The left musculocutaneous nerve pierced the coracobrachialis muscle and continued distally passing between the short head of the BBM and the additional heads located posterior to the BBM. It then gave off the variant musculocutaneous nerve to the median nerve. On both sides, the short and long heads of the BBM had normal origins, insertions, and courses. This novel variation has various clinical and embryological implications.

RESUMEN: Con frecuencia se observa una variación anatómica del músculo bíceps braquial (MBB); su patrón es diverso y clínicamente importante. Durante la disección de un cadáver masculino coreano de 78 años, se encontraron seis cabezas asimétricas adicionales del músculo bíceps braquial en ambos lados. En el lado derecho, dos cabezas adicionales se originaban en el húmero; el nervio musculocutáneo atravesaba entre estas cabezas y la cabeza corta del MBB. Se encontraron cuatro cabezas adicionales en el lado izquierdo, anterior al MBB, una de las cuales se originaba en el músculo pectoral mayor. Posterior al MBB, dos cabezas tendinosas se originaban en el músculo coracobraquial y una cabeza de vientre muscular se originaba en el húmero. El nervio musculocutáneo izquierdo perforaba el músculo coracobraquial y continuaba distalmente pasando entre la cabeza corta del MBB y las cabezas adicionales ubicadas por detrás del MBB. Luego emitía la variante el nervio musculocutáneo al nervio mediano. En ambos lados, las cabezas corta y larga del MBB tenían orígenes, inserciones y trayectos normales. Esta nueva variación tiene varias implicaciones clínicas y embriológicas.

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Purpose: Our purpose was to analyze the content and quality of YouTube videos related to distal biceps tendon (DBT) ruptures and repair. We aimed to compare differences between academic and nonacademic video sources. Methods: The most popular YouTube videos related to DBT injuries were compiled and analyzed according to source. Viewing characteristics were determined for each video. Video content and quality were assessed by 2 reviewers and analyzed according to the Journal of the American Medical Association benchmark criteria, DISCERN criteria, and a Distal Biceps Content Score. Cohen's kappa was used to measure interrater reliability. Results: A total of 59 DBT YouTube videos were included. The intraclass correlation coefficients ranged from moderate to excellent for the content scores. The mean DISCERN score was 29, and no videos were rated as either "good" or "excellent" for content quality. With the exception of the mean Journal of the American Medical Association criteria score (1.5 vs 0.5), videos from academic sources did not demonstrate significantly higher levels of content quality. Only 4/59 videos (7%) discussed the natural history of nonsurgically treated DBT ruptures. Of the 32 videos that discussed surgical techniques, only 3/32 (9%) had a preference for 2-incision techniques. No videos discussed the association between spontaneous DBT ruptures and cardiac amyloidosis. Conclusions: The overall content, quality, and reliability of DBT videos on YouTube are poor. Videos from academic sources do not provide higher-quality information than videos from nonacademic sources. Videos related to operative treatment of DBT ruptures more frequently discuss single-incision techniques. Clinical relevance: Social media videos can function as direct-to-consumer marketing materials, and surgeons should be prepared to address misconceptions regarding the management of DBT tears. Patients are increasingly seeking health information online, and surgeons should direct patients toward more reliable and vetted sources of information.

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INTRODUCTION: SLAP injuries are common in athletes but there is no consensus on different aspects such as pathophysiology and treatment options. Currently, the main controversy in the treatment of SLAP II injuries is deciding whether to make a repair or tenodesis. Clinical outcomes have varied according to the patients' age, sports, or work activity. This review aims to present the evidence at points of contention regarding pathophysiology, treatment options, outcomes, return to activities, and complications of type II SLAP. MATERIAL AND METHODS: The relevant literature on SLAP injuries and their treatment options and results were identified from PubMed and a narrative review was performed. RESULTS: Repairing SLAP II injuries seems to show better outcomes in younger patients and athletes who perform overhead movements, while tenodesis (in its various technical options) yields better outcomes in older patients, both as a single injury or associated with other pathologies such as rotator cuff injury or tenosynovitis. On the other hand, there currently seems to be a trend of increasing the indication of tenodesis even in underage patients and athletes, given that there are reports of fewer re-operations and a faster recovery. CONCLUSION: The evidence is unclear as to which factors influence the failure to achieve optimal outcomes even in cases with anatomical repairs. Studies with a high level of evidence including different variables are necessary to define when to repair, perform tenodesis, and what surgical technique to use for both options.

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