Arthroscopic suprapectoral and open subpectoral biceps tenodesis: a comparison of minimum 2-year clinical outcomes

Editorial Commentary: Biceps Tenodesis Fixation: Screw, Button, or None of the Above?

Clinical outcomes following shoulder subpectoral biceps tenodesis are generally favorable, with a very low complication rate (2%). One of the most devastating complications following this procedure is the occurrence of a proximal humerus fracture. Although all constructs have their unique advantages and disadvantages, creating a smaller bone hole while achieving good biomechanical outcomes is worth considering. This may be most advantageous in overhead-throwing athletes, tennis players, and/or volleyball athletes, who subject their shoulders to more torsional load due to the requirements of their sport. Thus, in addition to screws and buttons, smaller-diameter suture anchors could also be thoughtfully considered as a biceps tenodesis fixation option.

Biceps Tenodesis Versus Tenotomy in the Treatment of Lesions of the Long Head of the Biceps Tendon in Patients Undergoing Arthroscopic Shoulder Surgery: A Prospective Double-Blinded Randomized Controlled Trial

BACKGROUND

The biceps tendon is a known source of shoulder pain. Few high-level studies have attempted to determine whether biceps tenotomy or tenodesis is the optimal approach in the treatment of biceps pathology. Most available literature is of lesser scientific quality and shows varying results in the comparison of tenotomy and tenodesis.

PURPOSE

To compare patient-reported and objective clinical results between tenotomy and tenodesis for the treatment of lesions of the long head of the biceps brachii.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

Patients aged ≥18 years undergoing arthroscopic surgery with intraoperative confirmation of a lesion of the long head of the biceps tendon were randomized. The primary outcome measure was the American Shoulder and Elbow Surgeons (ASES) score, while secondary outcomes included the Western Ontario Rotator Cuff Index (WORC) score, elbow and shoulder strength, operative time, complications, and the incidence of revision surgery with each procedure. Magnetic resonance imaging was performed at postoperative 1 year to evaluate the integrity of the procedure in the tenodesis group.

RESULTS

A total of 114 participants with a mean age of 57.7 years (range, 34 years to 86 years) were randomized to undergo either biceps tenodesis or tenotomy. ASES and WORC scores improved significantly from pre- to postoperative time points, with a mean difference of 32.3% (P < .001) and 37.3% (P < .001), respectively, with no difference between groups in either outcome from presurgery to postoperative 24 months. The relative risk of cosmetic deformity in the tenotomy group relative to the tenodesis group at 24 months was 3.5 (95% CI, 1.26-9.70; P = .016), with 4 (10%) occurrences in the tenodesis group and 15 (33%) in the tenotomy group. Pain improved from 3 to 24 months postoperatively (P < .001) with no difference between groups. Cramping was not different between groups, nor was any improvement in cramping seen over time. There were no differences between groups in elbow flexion strength or supination strength. Follow-up magnetic resonance imaging at postoperative 12 months showed that the tenodesis was intact for all patients.

CONCLUSION

Tenotomy and tenodesis as treatment for lesions of the long head of biceps tendon both result in good subjective outcomes but there is a higher rate of Popeye deformity in the tenotomy group.

REGISTRATION

NCT01747902 ( ClinicalTrials.gov identifier).

Are Implant Choice and Surgical Approach Associated With Biceps Tenodesis Construct Strength? A Systematic Review and Meta-regression

BACKGROUND

Despite the increasing use of biceps tenodesis, there is a lack of consensus regarding optimal implant choice (suture anchor vs interference screw) and implant placement (suprapectoral vs subpectoral).

PURPOSE/HYPOTHESIS

The purpose was to determine the associations of procedural parameters with the biomechanical performance of biceps tenodesis constructs. The authors hypothesized that ultimate failure load (UFL) would not differ between sub- and suprapectoral repairs or between interference screw and suture anchor constructs and that the number of implants and number of sutures would be positively associated with construct strength.

STUDY DESIGN

Meta-analysis.

METHODS

The authors conducted a systematic literature search for studies that measured the biomechanical performance of biceps tenodesis repairs in human cadaveric specimens. Two independent reviewers extracted data from studies that met the inclusion criteria. Meta-regression was then performed on the pooled data set. Outcome variables were UFL and mode of failure. Procedural parameters (fixation type, fixation site, implant diameter, and numbers of implants and sutures used) were included as covariates. Twenty-five biomechanical studies, representing 494 cadaveric specimens, met the inclusion criteria.

RESULTS

The use of interference screws (vs suture anchors) was associated with a mean 86 N-greater UFL (95% CI, 34-138 N; P = .002). Each additional suture used to attach the tendon to the implant was associated with a mean 53 N-greater UFL (95% CI, 24-81 N; P = .001). Multivariate analysis found no significant association between fixation site and UFL. Finally, the use of suture anchors and fewer number of sutures were both independently associated with lower odds of native tissue failure as opposed to implant pullout.

CONCLUSION

These findings suggest that fixation with interference screws, rather than suture anchors, and the use of more sutures are associated with greater biceps tenodesis strength, as well as higher odds of native tissue failure versus implant pullout. Although constructs with suture anchors show inferior UFL compared with those with interference screws, incorporation of additional sutures may increase the strength of suture anchor constructs. Supra- and subpectoral repairs provide equivalent biomechanical strength when controlling for potential confounders.

Lateral Decubitus Position for Arthroscopic Suprapectoral Biceps Tenodesis

The purpose of this report is to describe arthroscopic suprapectoral biceps tenodesis in the lateral decubitus position. Many technique descriptions for this procedure emphasize the beach-chair position to obtain optimal anterior subdeltoid visualization of the relevant anatomy. This is not required and may be less desirable or comfortable for a shoulder arthroscopist who prefers the lateral decubitus position. Therefore, the aim of this report is to show that the relevant anatomy may be readily and safely accessed, and the procedure effectively performed, in the lateral decubitus position.

Open Biceps Tenodesis: A Biomechanical Comparison of 6 Fixation Techniques

Tenodesis is used to treat pathology of the long head of the biceps tendon. The authors evaluated the biomechanical properties of 6 techniques for biceps tenodesis fixation. The authors dissected 42 fresh-frozen cadaveric shoulders (mean age, 71±9.8 years; 69% male specimens), leaving the proximal humerus, proximal biceps tendon, and pectoralis major insertion. Specimens were randomized to undergo biceps tenodesis with one of the following: (1) an interference screw; (2) a cortical button; (3) a double-loaded 2.9-mm polyetheretherketone anchor (DL-2.9); (4) a double-loaded 1.9-mm all-suture anchor (DL-1.9); (5) a single-loaded 1.7-mm all-suture anchor (SL-1.7); or (6) soft tissue tenodesis. Specimens then underwent load-to-failure axial traction testing. A generalized linear and latent mixed model with a random-effects term was used to account for specimen pairing. Mean failure loads ranged from 136 N (95% confidence interval, 103-169 N) in the cortical button group to 79 N (95% confidence interval, 58-99 N) in the interference screw group. Failure occurred most often when fixation sutures pulled out of the tendon; however, 7 specimens failed elsewhere. No significant differences in ultimate failure load were found by treatment group. The interference screw group showed significantly more weakness than the cortical button and DL-2.9 groups. Tendon quality and suture parameters are likely more important than the fixation technique in determining failure load. [Orthopedics. 2020;43(2):e102-e108.].

Management of Failed Proximal Biceps Surgery: Clinical Outcomes After Revision to Subpectoral Biceps Tenodesis

BACKGROUND

The preferred surgical technique to manage biceps-superior labral pathology is often debated, and rates of revision and persistence of pain vary widely according to surgical technique and patient characteristics.

PURPOSE

To evaluate the clinical and functional outcomes of patients undergoing revision subpectoral tenodesis after failed primary tenodesis or tenotomy of the long head of the biceps.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

All patients undergoing revision biceps management by the senior surgeon between 2006 and 2016 and with a minimum 24-month follow-up were retrospectively identified. Patients being treated with concomitant rotator cuff repair or capsular release were excluded. Patient characteristic variables were recorded. Patient-reported outcomes including the functional score, Single Assessment Numeric Evaluation (SANE), visual analog scale (VAS), Simple Shoulder Test (SST), and American Shoulder and Elbow Surgeons were obtained, and range of motion, strength, and complications were quantified.

RESULTS

In total, 25 patients with revision biceps tenodesis were identified at a mean follow-up of 76.5 ± 31.5 months. The average age was 44.4 ± 14.3 years, and the surgical indications included failure of index suprapectoral biceps tenodesis (56%), subpectoral biceps tenodesis (36%), and patient dissatisfaction after tenotomy (8%). There was a significant improvement in the VAS score (P < .001), SANE (P = .001), SST (P = .035), functional score (P < .001), and forward elevation (P = .028), whereas postoperative strength (P = .440), abduction (P = .100), and external rotation (P = .745) improvement failed to achieve statistical significance after revision surgery. There was no difference in postoperative outcome measures between modes of failures, concomitant procedures, and sex. Twenty-two (88%) patients reported high satisfaction and stated they would have this revision surgery again. The overall complication rate was 48%, with half of these reporting pain of >3 on a scale of 10 and 4% of patients requiring additional surgeries.

CONCLUSION

The current study demonstrates high patient satisfaction (88%) and significant improvement in functional outcomes with revision biceps tenodesis, a mini-open subpectoral technique, after previous failed tenodesis or tenotomy. Although this may be an effective strategy to address failed prior biceps surgery, the potential complication of persistent pain must be emphasized. Patients should be counseled on the high complication rate (48%), with persistent pain being the most common complaint.

Complications of Arthroscopic Versus Open Biceps Tenodesis in the Setting of Arthroscopic Rotator Cuff Repairs: An Analysis of the American Board of Orthopaedic Surgery Database

INTRODUCTION

The purpose of this study was to compare complication rates between arthroscopic versus open biceps tenodesis in the setting of arthroscopic rotator cuff repair and to determine the effect of fellowship training on complication rates.

METHODS

The American Board of Orthopaedic Surgery database was used to identify cases of arthroscopic and open biceps tenodesis in the setting of rotator cuff repair between 2012 and 2016. Surgical, medical, and anesthetic complications, location, fellowship training, surgery year, and patient demographic data were recorded. Overall and specific complication rates were calculated and analyzed. Chi-square or Fisher exact tests were used to determine statistical significance.

RESULTS

Altogether, 1,725 cases of arthroscopic biceps tenodesis and 1,637 cases of open biceps tenodesis with arthroscopic rotator cuff repair were analyzed. No significant difference was found between overall complication rates between arthroscopic (11.4%) versus open (13.1%) biceps tenodesis (P = 0.14). Although open tenodesis had statistically significant higher rates of wound healing issues (0.7% versus 0.2%, P = 0.02), hematoma/seroma formation (0.5% versus 0.1%, P = 0.02), nerve injury (1.5% versus 0.4%, P < 0.01), deep vein thrombosis (0.49% versus 0.12%, P ≤ 0.05), and general anesthetic complications (0.75% versus 0.06%, P = 0.03), these rates remain comparably low. Shoulder arthroscopy fellowship-trained surgeons were more likely to use arthroscopic techniques than non-fellowship-trained surgeons (P < 0.01) but had a higher complication rate (P = 0.01).

DISCUSSION

No differences were found in overall complication rates between open and arthroscopic biceps tenodesis in the setting of rotator cuff repairs. Although open techniques had statistically significant higher rates of nerve injury, wound complications, and hematoma/seroma formation, this may not reflect clinical significance because these complication rates remained <2% in both techniques. Higher complication rates were seen among fellowship-trained surgeons, which may reflect greater case complexity. Both open and arthroscopic biceps tenodesis in the setting of rotator cuff repair show low complication rates, and the technique should be based on surgeon preference and patient factors.

LEVEL OF EVIDENCE

Level IV, case series.

Arthroscopic Suprapectoral and Open Subpectoral Biceps Tenodeses Produce Similar Outcomes: A Randomized Prospective Analysis

PURPOSE

To directly compare subjective and objective outcomes of arthroscopic suprapectoral biceps tenodesis (ASPBT) below the bicipital groove and open subpectoral biceps tenodesis (OSPBT) performed with interference screw fixation.

METHODS

A total of 77 patients indicated for biceps tenodesis who met the inclusion and exclusion criteria were randomized into the ASPBT and OSPBT groups. All tenodesis procedures implemented PEEK (polyether ether ketone) interference screws. Patients underwent a clinical examination that included range of motion and strength assessment at 3, 6, and 12 months postoperatively. Patients completed the American Shoulder and Elbow Surgeons (ASES) shoulder score, Single Assessment Numeric Evaluation score, and Constant score preoperatively and at 6 and 12 months postoperatively.

RESULTS

Seventy-five patients were analyzed with a mean age of 50.3 ± 10.4 years and a mean body mass index of 28.9 ± 6.3. All patients had arthroscopic evidence of biceps pathology and underwent either an ASPBT (n = 37) or OSPBT (n = 38). The surgical time was significantly greater for ASPBT than for OSPBT (16.9 ± 8.4 minutes vs 9.8 ± 3.1 minutes, P < .001). One patient underwent conversion from the ASPBT group to the OSPBT group because of shearing of a severely attenuated tendon preventing an ASPBT. No significant difference (P > .05) was found in strength or anterior shoulder pain at 3 months, 6 months, and 1 year, and no significant difference (P > .05) was found in clinical outcome scores (ASES, Constant subjective, and Single Assessment Numeric Evaluation) between the 2 groups at 6 months and 1 year. The improvement in the ASES score exceeded the minimal clinically important difference (12 points) in both groups.

CONCLUSIONS

No differences in patient-reported outcome measures, functional outcomes, or complication rates were found after ASPBT compared with OSPBT. However, the results of this investigation must be interpreted with caution because this study may be underpowered to detect statistical differences.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

Editorial Commentary: Aim High or Go Low? Outcomes Are Equivalent for Arthroscopic Suprapectoral and Mini-open Subpectoral Biceps Tenodesis

The contemporary management of biceps-labral pathology has increasingly transitioned toward primary treatment of the long head of the biceps tendon, largely in response to more consistent outcomes relative to SLAP repair and so-called benign neglect. Accordingly, there has been renewed interest in evaluating relevant differences between varying operative techniques and constructs for biceps tenodesis, including an array of subacromial, intra-articular, suprapectoral, and subpectoral methods. Among these, arthroscopic suprapectoral tenodesis and mini-open subpectoral tenodesis remain in contention for "best in show," albeit with distinctly different merits and risks. Important considerations with either technique include restoration of the native length-tension relation, avoidance of perioperative complications, surgical-site morbidity, and technical ease. Dogma aside, surgeons facile with both techniques can confidently counsel their patients on the comparable short-term results after suprapectoral or subpectoral biceps tenodesis.

Open subpectoral vs. arthroscopic proximal biceps tenodesis: A comparison study of clinical outcomes

The purpose of the present study was to compare the results of open subpectoral biceps tenodesis and arthroscopic proximal biceps tenodesis for treating long head of biceps (LHB) lesions. From January 2015 to June 2016, a total of 259 patients underwent LHB tenodesis surgery. Among them, 117 patients (60 females and 57 males) who met the inclusion and exclusion criteria were enrolled into the present study and were randomly divided into two groups, including an open subpectoral tenodesis group (OSPBT; n=62) and an arthroscopic proximal tenodesis group (ASPBT; n=55). All patients were followed up for at least 12 months. The demographic characteristics of each patient were recorded in detail. Moreover, clinical examinations of LHB lesions, such as shoulder range of motion (ROM), Visual Analog Scale (VAS) scores (0, no pain, to 10, most severe pain), American Shoulder and Elbow Surgeons (ASES) scores, and Constant-Murley shoulder outcome scores, were investigated prior to surgery, as well as 3, 6 and 12 months after surgery. Postoperative complications were also comprehensively investigated. There were no significant differences in sex, body mass index, dominant shoulder, duration of pain, injury type and operation time between the groups. The mean length of hospital stay in the ASPBT group was significantly lower than that of the OSPBT group (5.4±1.8 days vs. 9.3±2.9 days; P<0.05). The clinical outcomes, including shoulder ROMs, VAS scores, ASES scores and Constant-Murley shoulder outcome scores, were significantly improved after either OSPBT or ASPBT treatment. Specifically, the VAS score, incidence of postoperative stiffness and bicipital groove tenderness in the OSPBT group were significantly lower than those in the ASPBT group at 3 months post-surgery (P<0.05). Additionally, there were no significant difference in the improvement of other clinical outcomes and postoperative complications between the two groups. ASPBT and OSPBT were both effective and safe techniques for treating LHB lesions. However, tenderness of the bicipital groove was more common in the early stages of recovery post-surgery in the ASPBT group, which may be related to tendinitis of the LHB in the bicipital groove.

Arthroscopic Tenodesis of the Long Head Biceps Tendon Using a Double Lasso-Loop Suture Anchor Configuration

Multiple different techniques exist for performing a biceps tenodesis, and the literature has yet to define a particular technique as superior with respect to outcomes. Factors as the center of various clinical and biomechanical studies include analyzing arthroscopic versus open techniques, optimal fixation sites, and the use specific fixation devices (i.e., anchor, screw). This article details an all-arthroscopic approach for proximal tenodesis of the long head of the biceps tendon (LHBT) using a 2-portal method in a minimally invasive manner. Optimal biomechanical fixation of the LHBT is achieve by using 2 suture anchors in the creation of a dual lasso-loop configuration at the level of the bicipital groove. Technical pearls with respect to optimal arthroscopic viewing, efficient identification of the LHBT and subsequent release from the bicipital groove, and appropriate use of suture anchors for lasso-loop creation are presented for review. Two specific technical advantages of this technique include 2 fixation points for the LHBT to minimize failure risk, and smaller drill holes when compared with commonly performed tenodesis screw techniques to theoretically limit humeral fracture risk.

Lesions of the Long Head of the Biceps Tendon Concomitant with Rotator Cuff Tears: Tenotomy or Subpectoral Mini-open Tenodesis? A Comparative Short to Mid-term Follow-up Study

Objective

To compare the clinical and radiological outcomes of patients who underwent rotator cuff repair (RCR) concomitant with long head of the biceps tendon (LHBT) tenotomy or subpectoral mini‐open tenodesis.

Methods

Prospectively collected data was reviewed on 154 patients, who underwent a LHBT procedure (tenotomy or tenodesis) concomitant with RCR between January 2010 and January 2017. The exclusion criteria were irreparable massive rotator cuff tear, rotator cuff partial tear, subscapular tendon tear, glenohumeral arthritis, and prior shoulder surgery. The two patient groups are as follows: RCR + Tenotomy (Group A) and RCR + Subpectoral mini‐open tenodesis (Group B). The visual analog scale (VAS) for pain, Constant Score scale, American Shoulder and Elbow Surgeons (ASES) scores, and the Disabilities of the Arm, Shoulder and Hand (DASH) scores preoperatively and 1 month, 3 months, 6 months, 1 year postoperatively and the latest out‐patient clinic were compared between the two groups.

Results

Ninety‐two patients in Group A and 62 patients in Group B completed the follow‐up, with a median follow‐up time of 27 and 42 months respectively. At the final follow‐up, the VAS, Constant, ASES, and DASH scores in Group A were 0.1 ± 0.2, 87.0 ± 12.8, 96.4 ± 4.3 and 6.6 ± 4.8 respectively, and the VAS, Constant, ASES, and DASH scores in Group B were 0.1 ± 0.3, 92.5 ± 3.9, 96.3 ± 3.6 and 2.9 ± 1.3 respectively. Clinical evaluation scales showed satisfactory results in both groups, and there were no statistically significant differences between the two groups at the same follow‐up time. Popeye sign was detected in one case of Group A (1.1%) and in one case of Group B (1.6%, P > 0.05).

Conclusion

Both tenotomy and subpectoral mini‐open tenodesis are effective for concomitant lesions of the LHBT in patients with reparable rotator cuff tears, and subpectoral mini‐open tenodesis of the LHBT does not provide any significant clinical or functional improvement than isolated tenotomy.

SLAP IV IN OVERHEAD SPORTS PRACTICE

Superior labral tear from anterior to posterior (SLAP) is the most common disease in overhead sports practice.

A biomechanical comparison of two arthroscopic suture techniques in biceps tenodesis: whip-stitch vs. simple suture techniques

BACKGROUND

The aim of this study was to compare the biomechanical performance of whip-stitch (WS) and simple suture techniques (SST) of the long head of the biceps tendon in suprapectoral intraosseous tenodesis with interference screw fixation.

METHODS

A total of 10 paired cadavers (61.1 ± 4.6 years) were randomized to receive WS or SST biceps tenodesis beginning at the musculotendinous junction. Both groups implemented a No. 2 FiberLoop wire and underwent suprapectoral fixation with a polyetheretherketone interference screw at the bicipital grove. A Materials Testing System performed cyclic testing (500 cycles), followed by load to failure at 1 mm/s. Load, displacement, and time were recorded during cyclic and failure testing. A 2-tailed Student's t-test and χ² analysis were performed for failure load and mode of failure, respectively.

RESULTS

Two SST specimens and 1 WS specimen failed during cyclic loading via tendon rupture at the screw-tendon interface. There was no significant statistical difference in the cyclic displacement after 500 cycles between the WS (12.9 mm ± 4.4 mm) and SST groups (14.0 mm ± 3.8 mm, P = .2); cyclic strain, defined as the peak displacement at the 500th cycle divided by the initial gauge length, between the WS (0.4 ± 0.2) and SST groups (0.7 ± 0.7, P = .3); maximal load (162.7 N ± 56.8 N vs. 153.1 N ± 39.3 N, respectively, P = .6); and stiffness (50.5 N/mm ± 17.7 N/mm vs. 43.3 N/mm ± 10.9 N/mm, respectively, P = .3). All specimens ruptured at the screw-tendon interface.

CONCLUSION

The WS technique can provide equivalent biomechanical performance to the SST in suprapectoral intraosseous biceps tenodesis with interference screw fixation.

Rotator cuff tear with concomitant long head of biceps tendon (LHBT) degeneration: what is the preferred choice? Open subpectoral versus arthroscopic intraarticular tenodesis

BACKGROUND

Lesions associated with the biceps tendon are commonly detected during arthroscopic repair of rotator cuff tears. Acquiring a preferable technique to repair both cuff and long head of biceps tendon (LHBT) lesions was the aim of several recent studies. This study aimed to compare clinical and functional outcomes of open subpectoral versus arthroscopic intraarticular tenodesis in patients with repairable rotator cuff tear associated with LHBT degeneration.

PATIENTS AND METHODS

In this randomized clinical trial, 60 eligible candidates for arthroscopic rotator cuff repair (mean age 55.7 ± 6.9 years) were allocated to a control group (open subpectoral, SP) or intervention group (intraarticular, IA). In the IA group, an anchor suture was used for both rotator cuff repair and LHBT tenodesis. In the SP group, after arthroscopic repair of the rotator cuff, subpectoral tenodesis of LHBT was performed using an interference screw. Patients were evaluated for 2 years follow-up regarding pain intensity using the visual analogue scale (VAS) and shoulder function using the Constant Score and Simple Shoulder Test.

RESULTS

The two groups were similar with regard to demographic characteristics and preoperative evaluations (all P > 0.05). The functional status of both groups was improved, but not significantly differently so between the two groups (P = 0.1 and P = 0.4, respectively). Pain intensity decreased during the 2-year follow-up period, similarly so in the two groups. Patient satisfaction was also similar in the two groups.

CONCLUSION

Large and massive rotator cuff tears (tears > 3 cm) associated with LHBT pathologies benefited from intraarticular or subpectoral tenodesis similarly, with no differences in short- or mid-term results between these two techniques.

LEVEL OF EVIDENCE

II.

Biomechanical Analysis of All-Suture Suture Anchor Fixation Compared With Conventional Suture Anchors and Interference Screws for Biceps Tenodesis

PURPOSE

To compare the biomechanical properties of all-suture suture anchors (ASSAs) with conventional interference screws (CISs) and conventional suture anchors (CSAs) for long head of the biceps tendon fixation during proximal biceps tenodesis (BT).

METHODS

We randomized 21 fresh-frozen human cadaveric shoulders into 3 subpectoral BT treatment groups: ASSA, CSA, and CIS. Each construct was cyclically loaded from 5 to 70 N for 500 cycles (1 Hz). All specimens that survived cyclic loading were then pulled to failure (1 mm/s). Elongation, maximum load, energy, and failure mode were recorded. The humerus was stripped of tissue and then subjected to torsional displacement at a rate of 1°/s until fracture occurred. Maximum load, displacement, stiffness, and energy were recorded.

RESULTS

During tendon testing, 3 specimens (43%) in the CIS group failed early during cyclic testing by the tendon tearing at the screw-tendon interface. All other specimens in the CIS group, as well as all specimens in the ASSA and CSA groups, survived cyclic testing and failed during pull-to-failure testing. Failure occurred at the tendon-anchor or -screw interface in all specimens (100%), with no anchor or screw pullout. The CIS group had significantly decreased elongation (8.9 ± 2.23 mm) at maximum load compared with the ASSA (19.2 ± 5.2 mm) and CSA (18.9 ± 2.23 mm) groups (P = .001). During torsional testing, the ASSA group was able to withstand significantly greater torsional displacement (9.22° ± 0.86°) before failure and had greater energy to failure (497.3 ± 45 Nmm-degrees) than the CIS group (6.13° ± 1.24° and 256.6 ± 70.3 Nmm-degrees, respectively; P = .005).

CONCLUSIONS

This study shows that the biomechanical properties of ASSA, CSA, and CIS constructs are similar. The interference screw group had lower tendon elongation at maximum load but had several early failures compared with the suture anchor groups. The use of suture anchors results in maximum tendon and torsional bone loads similar to interference screws for the long head of the biceps tendon. Torsional testing of the CIS resulted in spiral fractures traversing the screw tunnel in 100% of the specimens, which was not found in the suture anchor groups.

CLINICAL RELEVANCE

The ASSA is a viable fixation method for BT in comparison with the CSA and CIS.

[Modern treatment strategies for the long head of the biceps tendon]

The long head of the biceps and the biceps pulley sling are prone to acute or degenerative injury. As they both were identified as major pain generators, adequate diagnosis and treatment is vital for successful treatment of shoulder pain. Although the basic principles to address either pathology have not changed over the last decades, new trends have evolved to simplify surgical options. SLAP (superior labral tear from anterior to posterior) repair is seen more restrictive and is mostly performed in young individuals, whereas tenotomy or tenodesis are more often used in patients over 30. The long head of the biceps and pulley lesions are treated with either tenotomy or tenodesis. Surgical techniques for tenodesis are especially less invasive using current implants. Tenodesis is performed either intraarticular, supra- or subpectoral with tenodesis screws or suture anchors. Soft tissue tenodesis has become unpopular over the last decade. Surgical treatment of the long head of the biceps pathologies allows highly satisfying results if the indication is chosen thoroughly.

Editorial Commentary: Back to Work After Shoulder Biceps Tenodesis!!

Assessing the time and factors influencing return to work after any procedure is very important. It helps in both preoperative counseling of patients and gives them a clear picture of the time needed to get back to work. Very few studies have commented on return to work after shoulder biceps tenodesis. In most patients, average time to return to work approximates 5 months; however, for a specific patient, the time to return to work is quite variable and multifactorial. It is important that future studies also analyze the factors and the time to return to preinjury work status.

Establishing minimal clinically important difference, substantial clinical benefit, and patient acceptable symptomatic state after biceps tenodesis

BACKGROUND

The purposes of this study were to establish thresholds for improvement in patient-reported outcome scores that signify the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) after biceps tenodesis (BT) and to assess patient variables that are associated with these clinically important outcomes.

METHODS

A prospectively maintained institutional shoulder registry was queried for patients undergoing isolated BT between 2014 and 2017. Anchor-based and distribution-based approaches were used to calculate the MCID whereas an anchor-based method was used to calculate the SCB and PASS for the Constant-Murley score, Single Assessment Numerical Evaluation (SANE) score, and American Shoulder and Elbow Surgeons score.

RESULTS

A total of 123 patients who underwent isolated BT were included for analysis. The MCID, SCB, and PASS calculated for the American Shoulder and Elbow Surgeons score were 11.0, 16.8, and 59.6, respectively. For the Constant-Murley score, the calculated MCID and PASS were 3.8 and 19.5, respectively. The MCID, SCB, and PASS calculated for the SANE score were 3.5, 5.8, and 65.5, respectively. The following patient variables were significantly associated with decreased odds of achieving the MCID: workers' compensation status, male sex, and higher preoperative SANE score. Patients with a history of ipsilateral shoulder surgery had significantly reduced odds of achieving SCB. The only factor significantly associated with failing to reach the PASS was workers' compensation status.

CONCLUSION

This study established values for the MCID, SCB, and PASS after BT without concomitant rotator cuff repair. Workers' compensation status, previous shoulder surgery, male sex, and higher preoperative patient-reported outcome measure scores are associated with lower odds of achieving clinically significant improvement after BT.

Incidence and Characteristics of Humeral Shaft Fractures After Subpectoral Biceps Tenodesis

Background:

Biceps tenodesis is a procedure that can address biceps and labral pathology. While there is an increased risk of humeral fracture after biceps tenodesis, it has been described only in case reports.

Purpose:

To identify the incidence, demographics, and characteristics of humeral shaft fractures after biceps tenodesis.

Study Design:

Case series; Level of evidence, 4.

Methods:

The US Military Health System Data Repository was searched for patients with a Current Procedural Terminology code for biceps tenodesis between January 2013 and December 2016. The cohort of identified patients was then searched for those assigned a code for humeral fracture per the International Classification of Diseases, 9th Revision and 10th Revision. The electronic health records and radiographs of patients who were diagnosed with a humeral fracture were then evaluated to confirm that the fracture was related to the biceps tenodesis. Records were then reviewed for patient demographics, radiographs, operative reports, and clinical notes.

Results:

A total of 15,085 biceps tenodeses were performed between January 2013 and December 2016. There were 11 postoperative and 1 intraoperative humeral fractures. The incidence of fracture was <0.1%. All fractures were extra-articular spiral fractures that propagated through the tenodesis site. Eight patients were treated with functional bracing, 3 with open reduction and internal fixation, and 1 with a soft tissue biceps tenodesis revision. Of 8 patients successfully treated nonoperatively, 6 regained full range of shoulder motion. Only 2 of the 4 patients who required operative treatment regained full range of shoulder motion.

Conclusion:

Humeral shaft fracture after biceps tenodesis is a rare complication that occurs in 7.9 out of 10,000 cases. Fractures occurred after various methods of fixation, including suture anchor, cortical button, and interference screw. Most patients were initially treated nonoperatively, and those who healed usually achieved full range of motion; however, those who required operative intervention often had restricted range of motion on final follow-up. Future studies should determine risk factors for fracture after biceps tenodesis.

Complications of biceps tenodesis based on location, fixation, and indication: a review of 1526 shoulders

BACKGROUND

Long head of the biceps tendon (LHBT) tenodesis is predominantly performed for 2 reasons: anterior shoulder pain (ASP) or structural reasons (partial tear, dislocation).

METHODS

Between 2006 and 2014, all cases of primary LHBT tenodesis performed at an integrated health care system were retrospectively reviewed. Complications were analyzed by tenodesis location (below or out of the groove [OOG] vs leaving tendon in the groove [ITG]), fixation method (soft tissue vs implant), and indication (preoperative ASP vs structural).

RESULTS

Among 1526 shoulders, persistent ASP did not differ by fixation method (11.0% for implant vs 12.8% for soft tissue, P = .550) or location (10.8% for OOG vs 12.9% for ITG, P = .472). Soft-tissue tenodesis cases had more frequent new-onset ASP (11.9% vs 2.6%, P < .001) and subjective weakness (8.50% vs 3.92%, P < .001) but less frequent revisions (0% vs 1.19%, P = .03) than implant tenodesis cases. No difference was found between ITG and OOG for persistent ASP (12.9% vs 10.8%, P = .550), new-onset ASP (6.5% vs 2.8%, P = .339), cramping (1.70% vs 2.31%, P = .737), deformity (4.72% vs 4.62%, P = .532), or subjective weakness (6.23% vs 4.32%, P = .334), but ITG cases had more revisions (1.51% vs 0.60%, P = .001). Among implant tenodesis cases, 1 shoulder (0.085%) sustained a fracture.

CONCLUSION

The overall complication rate of LHBT tenodesis was low. Of the shoulders, 10.8% to 12.9% continued to have ASP, regardless of whether the LHBT was left ITG. Soft-tissue tenodesis cases had higher rates of new-onset ASP and subjective weakness. No significant difference for tenodesis ITG or OOG was found in biceps-related complications.

Preoperative Shoulder Injections Are Associated With Increased Risk of Revision Rotator Cuff Repair

PURPOSE

The goal of this study was to determine whether the timing of preoperative shoulder injections is associated with an increased risk of revision rotator cuff repair following primary rotator cuff repair (RCR).

METHODS

A retrospective analysis of claims data of privately insured subjects from the MarketScan database for the years 2010 to 2014 was conducted. Multivariable logistic regression models were used to compare the odds of reoperation between groups. Laterality for the injection, index procedure, and subsequent surgery were verified for all subjects.

RESULTS

A total of 4,959 subjects with an arthroscopic RCR were identified, 392 of whom required revision RCR within the following 3 years. Patients who had an injection within 6 months preceding the index surgery were at a much higher risk of undergoing reoperation for revision RCR: 0 to 3 months prior, adjusted odds ratio (AOR) 1.375 (95% confidence interval [CI], 1.027-1.840); 3 to 6 months prior, AOR 1.822 (95% CI, 1.290-2.573); and 6 to 12 months prior, AOR 1.237 (95% CI, 0.787-1.943).

CONCLUSIONS

Patients who had received an injection within 6 months prior to RCR were much more likely to undergo a revision cuff repair within the following 3 years. The risk of reoperation significantly declines if there is more than 6 months between injection and RCR. Consideration should be given to minimizing preoperative injections in patients requiring RCR or delaying primary RCR for 6 months following injection.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Rates and Risk Factors for Revision Open and Arthroscopic Proximal Biceps Tenodesis

Background:

Biceps tenodesis may be performed for symptomatic tendinopathy or tearing of the long head of the biceps tendon. Biceps tenodesis is also commonly performed as an adjunctive procedure. However, the indications and prevalence of biceps tenodesis have expanded.

Purpose:

To establish the incidence and risk factors for revision biceps tenodesis.

Study Design:

Case-control study; Level of evidence, 2.

Methods:

The PearlDiver database of Humana patient data was queried for patients undergoing arthroscopic or open biceps tenodesis (Current Procedural Terminology [CPT] 29828 and CPT 23430, respectively) from 2008 through the first quarter of 2017. Patients without a CPT laterality modifier were excluded from analysis. Revision biceps tenodesis was defined as patients who underwent subsequent ipsilateral open or arthroscopic biceps tenodesis. The financial impact of revision biceps tenodesis was also calculated. Multivariate binomial logistic regression was performed to identify risk factors for revision biceps tenodesis, such as patient demographics as well as concomitant procedures and diagnoses. Odds ratios (ORs) and 95% CIs were calculated, and all statistical comparisons with P < .05 were considered significant.

Results:

There were 15,257 patients who underwent biceps tenodesis. Of these, 9274 patients (60.8%) underwent arthroscopic biceps tenodesis, while 5983 (39.2%) underwent open biceps tenodesis. A total of 171 patients (1.8%) and 111 patients (1.9%) required revision biceps tenodesis after arthroscopic and open biceps tenodesis, respectively (P = .5). Male sex (OR, 1.38 [95% CI, 1.04-1.85]; P = .02) was the only independent risk factor for revision biceps tenodesis after the index open biceps tenodesis. After arthroscopic biceps tenodesis, age >45 years (OR, 0.58 [95% CI, 0.39-0.89]; P = .01) and concomitant rotator cuff tear (OR, 0.58 [95% CI, 0.47-0.71]; P < .001) were independent protective factors for revision biceps tenodesis. The total cost of revision biceps tenodesis after open and arthroscopic biceps tenodesis was US$3427.95 and US$2174.33 per patient, respectively.

Conclusion:

There was no significant difference in the revision rate between arthroscopic and open biceps tenodesis. Risk factors for revision surgery included male sex for open biceps tenodesis, while age >45 years and rotator cuff tears were protective factors for arthroscopic biceps tenodesis.

Biceps tenodesis versus biceps tenotomy for biceps tendinitis without rotator cuff tears

Disorders of the long head of the biceps tendon (LHB) are a well-recognised cause of shoulder pain despite the function of the long head of the biceps remaining poorly understood. There has been a dramatic rise in the number of biceps tenodesis procedures being performed in the last decade. This may partly be attributed to concerns regarding residual cosmetic deformity and pain after biceps tenotomy though there is little evidence to suggest that functional outcomes of tenodesis are superior to biceps tenotomy. Current literature focuses on LHB disorders with concomitant rotator cuff tears. The aim of this review is to discuss the anatomy of the LHB, the pathogenesis of tendinopathy of the LHB, indications of biceps tenodesis and tenotomy and compare the current literature on the functional outcomes of these procedures for LHB disorders in the absence of rotator cuff tears.

Arthroscopic extra-articular suprapectoral biceps tenodesis with knotless suture anchor

Tenodesis of the long head of the biceps tendon is a frequently performed procedure during shoulder arthroscopy. Various open and arthroscopic techniques have been described with comparable outcomes and complication rates. We describe a simple, knotless, arthroscopic extra-articular biceps tenodesis technique using a 4.5-mm knotless anchor. This technique avoids the complications associated with open tenodesis surgery while still removing the diseased biceps tendon from the bicipital groove. The benefits from knotless suture anchor include no requirement of arthroscopic knot tying and no risk of the knot irritation under the coracoid and coracoacromial ligament.

Regional histologic differences in the long head of the biceps tendon following subpectoral biceps tenodesis in patients with rotator cuff tears and SLAP lesions

PURPOSE

The purpose of this study was to quantify the regional histology of the long head of the biceps tendon (LHBT) and compare the histopathology present to clinical findings in patients with rotator cuff tears and SLAP lesions.

METHODS

Prospectively enrolled patients undergoing an open subpectoral LHBT tenodesis in the setting of a rotator cuff (RTC) tear or SLAP lesion. Perioperative data were collected and the excised LHBT was analyzed by a fellowship trained pathologist. Tendons were sectioned into proximal (biceps anchor), middle (bicipital groove), and distal (myotendinous junction) portions. Sections were stained with Movat's pentachrome stain and digitized for analysis. Comparisons were made between the histologic findings present in the setting of a rotator cuff tear with those seen in the setting of a SLAP tear.

RESULTS

39 tendons were analyzed: 20 from patients with SLAP lesions (mean age of 44.7 years, range 23-60 years) and 19 from patients with rotator cuff tears (mean age of 58.7 years, range 43-71). Patients with the most pathologic tendons in the bicipital groove were significantly older (59.4 vs. 50.4 years; p < 0.05), reported higher pre-operative VAS scores (6.6 vs. 5.0; p < 0.02), and demonstrated lower pre-operative ASES scores (41.6 vs. 50.7; p < 0.05). The RTC group showed significantly more mucinous degeneration at both the proximal (p < 0.03) and the middle (p < 0.01) tendon portions compared to the SLAP group. In both groups, the portions of proximal tendon showed significantly (p < 0.05) more mucinous degeneration than distal portions.

CONCLUSION

Regional histologic differences exist in the LHBT. Rotator cuff patients showed the most degenerated tendon in the bicipital groove and these patients tended to be older and have higher VAS and lower ASES scores. Surgeons should consider performing a subpectoral biceps tenodesis as the bicipital groove portion of the tendon may be very degenerated, especially in patients with rotator cuff disease. Additional research is warranted to distinguish whether treating the biceps differently in distinct geographic regions affects patient outcomes.

LEVEL OF EVIDENCE

II.

Anatomic landmarks for arthroscopic suprapectoral biceps tenodesis: a cadaveric study

BACKGROUND

Biceps tenodesis reduces the incidence of Popeye deformity occurring with tenotomy, but pain may occur with tenodesis superior to or within the bicipital groove. Arthroscopic suprapectoral tenodesis is an attractive alternative. The purpose of this study was to establish landmarks for arthroscopic suprapectoral tenodesis and determine the appropriate fixation point to optimize muscle tension.

METHODS

Twelve fresh cadaveric shoulders were dissected. Urethane polymer was injected into the axillary artery. The position of the anterior branch of the axillary nerve was marked. The transverse humeral ligament was split, exposing the biceps (long head of the biceps [LHB]) from its origin to the pectoralis major tendon (PMT). The intra-articular portion was released. Measurements were taken from the proximal tendon to described landmarks.

RESULTS

The mean length of the intra-articular LHB was 2.53 cm (range, 1.72-3.55 cm). The mean distance from the LHB origin to the inferior lesser tuberosity (LT) was 5.58 cm (range, 4.02-6.87 cm), and that to the superior border of the PMT was 8.46 cm (range, 6.46-10.78 cm). The suprapectoral tenodesis zone (inferior LT to superior PMT) was 2.96 cm (range, 1.54-4.40 cm). In all specimens, a branch of the anterior humeral circumflex arose medial to the LHB and distal to the LT and crossed the suprapectoral zone from medial to lateral at 1.49 ± 0.42 cm proximal to the PMT, approximately at the level of the axillary nerve. The musculocutaneous nerve was on average 3.06 cm (range, 1.86-3.76 cm) from the tenodesis zone.

CONCLUSION

A branch of the anterior humeral circumflex is a reliable landmark for identifying the mid-suprapectoral zone. The distance from the proximal LHB tendon to this crossing vessel averaged 6.32 cm in female specimens and 8.28 cm in male specimens. These findings allow appropriate tensioning of the LHB during arthroscopic suprapectoral tenodesis.

Clinical Evaluation of an Arthroscopic Knotless Suprapectoral Biceps Tenodesis Technique: Loop 'n' Tack Tenodesis

Background:

Pathology of the long head of the biceps tendon is a well-known cause of shoulder pain that is commonly managed with arthroscopic suprapectoral biceps tenodesis when conservative treatment fails.

Purpose:

To present an arthroscopic knotless suprapectoral biceps tenodesis technique known as “Loop ’n’ Tack” tenodesis and to report the clinical outcomes of patients with a minimum 2 years of follow-up.

Study Design:

Case series; Level of evidence, 4.

Methods:

A retrospective review of all patients who had undergone Loop ’n’ Tack tenodesis between January 2009 and May 2014 was completed. Charts were reviewed, and patients were contacted for demographic data, time from surgery, concomitant procedures, and workers’ compensation status, as well as visual analog scale for pain, American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation, and University of California, Los Angeles (UCLA) scores.

Results:

Complete follow-up evaluations were performed for 59 of 68 patients (87%). Mean follow-up was 43 months. A majority (88%) of patients had at least 1 additional procedure performed at the time of biceps tenodesis. The mean ASES shoulder score improved from 42.6 preoperatively to 91.0 postoperatively (P < .001), and 54 of 59 patients (91.5%) had a good/excellent outcome, with a UCLA shoulder score >27 and ASES shoulder score >70. Three patients (5%) reported biceps cramping pain with overuse, and 2 (3.3%) reported intermittent anterior shoulder pain. No patients had developed a “Popeye” deformity at final clinical examination, and 97% reported that they were overall satisfied with the procedure.

Conclusion:

The Loop ’n’ Tack tenodesis technique results in a high rate of patient satisfaction, significant improvement in shoulder outcome scores, and a low incidence of postoperative pain, with no reoperations for biceps-related pathology.

Editorial Commentary: How Can I Tenodese the Biceps Tendon of the Shoulder? Let Me Count the Ways

The debate regarding the management of long head of the biceps tendon pathology continues to evolve. Previous literature has compared tenotomy and tenodesis, tenodesis above or below the pectoralis major tendon, tenodesis to bony or soft tissue sites, and a host of fixation methods. Recent research compares biomechanical fixation between an all-suture anchor and interference screw for arthroscopic tenodesis. Although the methods have similar biomechanical properties, time-zero cadaveric data has inherent limitations, and importantly, there is a substantial cost differential between these and other implants that surgeons should also consider when choosing a tenodesis method.

Factors Affecting Cost, Outcomes, and Tendon Healing After Arthroscopic Rotator Cuff Repair

BACKGROUND

The purpose of this study was to simultaneously examine costs, functional outcomes, and tendon healing after arthroscopic rotator cuff repair.

METHODS

This was a retrospective, single-surgeon, single-hospital study. Pre- and postoperative Simple Shoulder Test (SST), visual analog scale (VAS) pain, and American Shoulder and Elbow Surgeons (ASES) scores, and postoperative magnetic resonance images (MRIs) were obtained. Direct costs were derived using a unique, validated tool. Costs included overall total direct cost, which included facility use costs, medication costs, supply costs, and other ancillary costs.

RESULTS

85 patients had a minimum 1-year follow-up of functional outcomes (mean of 1.24 years, range 1-3.2 years) and 56 of 85 (66%) had postoperative MRI healing data at an average follow-up of 1.3 years (range 1-3.2 years). Increased direct cost was associated with ASA class III (P < .001) compared with ASA class I, procedures performed at the main operative room (P = .017) compared with those at the surgical center, single-row repair (P < .001) compared with double-row repair, medium and large tear sizes (P < .001 and P = .001) compared with small tear, and increased number of anchors (P ≤ .001 or P < .039 for each additional). Arthroscopic biceps tenodesis was associated with decreased improvement in SST, VAS-pain, and ASES scores (P < .001, .012, and .024), whereas infraspinatus atrophy and large/massive tear size was associated with decreased improvement in ASES scores (P = .03). Obesity (P = .004) and smoking (P = .034) were associated with greater improvement in VAS-pain scores as these were associated with decreased preoperative scores. Seventy percent of tears healed.

CONCLUSIONS

Within our study, factors that increased direct costs were outcome neutral, and factors that improved outcome were cost neutral.

LEVEL OF EVIDENCE

Level IV, retrospective.

Arthroscopic Suprapectoral Biceps Tenodesis With Tenodesis Screw

There are many methods for long head of the biceps tendon (LHBT) tenodesis, but a consensus on a superior method has yet to be met. In this article, we introduce a method for arthroscopic suprapectoral biceps tenodesis using a tenodesis screw in the bicipital tunnel. The intra-articular portion of the biceps tendon is transected. The subdeltoid space is then viewed via a lateral portal, and the tendon is mobilized from the bicipital tunnel. The tendon is retrieved through the anterior portal, and 5 whipstitch passes and a second distal stitch are placed. Three of the suture tails are passed through the tenodesis screwdriver, and the tendon is maneuvered to the previously reamed bone socket located 1.5 cm superior to the pec tendon, just inferior to the bicipital groove. Once the tenodesis screw is fixated in sufficient bone stock, 5 alternating half hitches reinforce the construct by creating a closed loop through the screw. This described technique allows full visualization of the LHBT dissection and tenodesis throughout the procedure. Additionally, this technique provides a method to incorporate whipstitching with an arthroscopic tenodesis screw to provide additional strength to tendon fixation.

Subpectoral Biceps Tenodesis With PEEK Interference Screw: A Biomechanical Analysis of Humeral Fracture Risk

PURPOSE

To quantify the torsional load to fracture for subpectoral biceps tenodesis with interference screw fixation.

METHODS

We randomized 28 specimens from 14 matched-pair full-length humeri (mean age, 55.3 years) into 3 groups: (1) empty ream group (ERG), (2) screw-only group (SOG), and (3) screw-plus-biceps tendon group (SBG). In each group, 1 humerus of each matched pair was prepared according to group allocation and the contralateral humerus remained intact as a control. In the ERG, an 8-mm unicortical hole was reamed 1 cm proximal to the inferior border of the pectoralis major tendon insertion; in the SOG, the humerus was filled with an 8-mm × 12-mm PEEK (polyether ether ketone) screw; and in the SBG, the humerus was filled with a PEEK screw and the cadaveric long head of the biceps tendon. Humeri were tested under torsional displacement at a rate of 1°/s until fracture. Maximum torque, energy to maximum torque, and linear stiffness were used to assess humerus strength.

RESULTS

Compared with contralateral intact specimens, the maximum torque to fracture was reduced by 28% in the ERG (P = .005), 30% in the SOG (P = .014), and 20% in the SBG (P = .046). Energy to maximum torque was similarly reduced in the ERG (P = .007), SOG (P = .023), and SBG (P = .049). Stiffness was increased by 4% in the ERG (P = .498), 9% in the SOG (P = .030), and 4% in the SBG (P = .439).

CONCLUSIONS

Drilling an 8-mm unicortical hole in zone 3 of the bicipital tunnel for open subpectoral biceps tenodesis reduces the torsional load to humeral fracture up to 28% at time 0. The addition of a PEEK tenodesis screw alone reduced the maximum torque by 30%, and the addition of a screw with the long head of the biceps tendon reduced the maximum torque by 20%. The total load to fracture was reduced in all settings. Stiffness was not significantly different for the ERG and SBG, but stiffness was significantly higher for the SOG compared with the intact matched humeri at time 0.

CLINICAL RELEVANCE

When performing a biceps tenodesis, humeral fracture susceptibility is increased with an applied torsional load at time 0. Thus providers must be aware of this reduced integrity when a subpectoral biceps tenodesis is used.

Subpectoral Biceps Tenodesis for Treatment of Isolated Type II SLAP Lesions in a Young and Active Population

PURPOSE

The purpose of this study was to evaluate outcomes following open subpectoral biceps tenodesis for the treatment of isolated type II SLAP lesions in patients 45 years of age or younger and evaluate the rate of return to sport.

METHODS

All patients included in the study were at least 2 years out from open subpectoral biceps tenodesis for treatment of an isolated type II SLAP lesion and were treated between December 2007 and March 2015. All patients older than 45, those who had prior surgery on the index shoulder, and those who had any concomitant reconstructive shoulder procedures were excluded. American Shoulder and Elbow Surgeons (ASES), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), Single Assessment Numeric Evaluation (SANE), and Short-Form 12 Physical Component Summary (SF-12 PCS) scores were collected pre- and postoperatively along with postoperative patient satisfaction. Patient return to sport was evaluated by questionnaire.

RESULTS

Twenty patients with a mean age of 38 years (range 21-45) were included, of which 16 were available for follow-up. There was significant improvement in median pre- to postoperative outcome scores (ASES, 66-94 points, P = .001; QuickDASH, 31-8, P = .003; SANE, 60-92, P = .001, SF-12 PCS, 41-52 points, P = .002), with a median patient satisfaction of 8.5 points (range 1-10) at a mean follow-up of 3.4 years (range, 2.0-6.3 years). At final follow-up, all patients had returned to sport, with 73% of patients indicating a return to their previous or comparable level of sports. Subgroup analysis showed 80% of overhead athletes returned to the same or a comparable level postoperatively.

CONCLUSIONS

This study suggests that young patients around their 30s participating in sport at a recreational level may benefit from open subpectoral biceps tenodesis for a primary isolated SLAP II tear and would experience excellent outcomes, high satisfaction, and a high rate of return to sport.

LEVEL OF EVIDENCE

Level IV, therapeutic case study.

Clinical and sonographic evaluation of subpectoral biceps tenodesis with a dual suture anchor technique demonstrates improved outcomes and a low failure rate at a minimum 2-year follow-up

INTRODUCTION

The purpose of this study was to evaluate the clinical outcomes and integrity of an open subpectoral biceps tenodesis using a dual suture anchor construct.

MATERIALS AND METHODS

Patients with at least 2 years of follow-up were retrospectively evaluated for simple shoulder test (SST), American Shoulder and Elbow Surgeons (ASES) score, and visual analog scales (VAS) for pain, function and satisfaction. A physical exam assessed shoulder range of motion and elbow strength. Ultrasonography visualized construct integrity.

RESULTS

Of 43 eligible patients, 36 completed questionnaire evaluation and 22 completed an additional physical examination. Indications included superior labral anterior-posterior (SLAP) lesions (4), partial thickness tears (6), instability (6), and tenosynovitis of the biceps tendon (20). Eighteen patients (50%) had an associated rotator cuff tear. Patient-reported outcomes improved pre- vs postoperatively: ASES score (45.4 vs 78.6, P < 0.001), SST (5.1 vs 9.6, P < 0.001), pain-VAS (4.8 vs 2.0, P < 0.001), and function-VAS (4.9 vs 2.3, P < 0.001). Satisfaction-VAS was 8.3 postoperatively. Patient-reported outcomes did not differ for patients with an associated rotator cuff tear compared to those without (P ≥ 0.427). None of the physical exam measures were lower on the operative side compared to the healthy side (P ≥ 0.516). Sonographic evaluation revealed preserved integrity of the tenodesis construct in all cases. No complications were noted.

CONCLUSIONS

Subpectoral biceps tenodesis utilizing a dual suture anchor technique is a treatment option for SLAP lesions, partial thickness tears, subluxation, and tenosynovitis of the long head of the biceps with high rates of postoperative patient satisfaction, a low failure rate, and improved outcome scores. The presence of a concomitant rotator cuff tear did not influence clinical outcomes.

Open subpectoral biceps tenodesis in patients over 65 does not result in an increased rate of complications

Background

Long head biceps tendon pathology is a common cause of anterior shoulder pain and is often associated with other shoulder conditions, such as rotator cuff tears and osteoarthritis. It is well accepted that older patients are at increased risk for major and minor peri- and postoperative complications.

The purpose of this study is to investigate patients over 65 years old who underwent subpectoral biceps tenodesis and compare the complication rates of this group to those of patients younger than 65 years old. The hypothesis is, that there would be no difference in complication rates and that clinical outcome scores for patients over 65 were satisfying and showed improvements over time.

Methods

There were 337 patients who underwent open subpectoral biceps tenodesis, between January 2005 and June 2015, 23 were identified as being over the age of 65 with a minimum follow up of 12 months. All patients over the age of 65 were evaluated pre- and postoperatively using Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons (ASES), Constant-Murley (CM) and Single Assessment Numeric Evaluation (SANE). Intraoperative and postoperative adverse events (fracture, infection, wound opening, rupture/failure and neurovascular injuries) related to the tenodesis procedure and to the surgery itself were collected from all 337 patients in a routine postoperative follow-up.

Results

The under 65 group (range 27–64 years) at an average follow up (FU) of 30 months (range 12–91 months) showed a 5.4% (17 out of 314) post-operative complication rate related to the subpectoral tenodesis, whereas the group over 65 (range 65–77 years) at an average follow up of 33 months (range 12–79 months) showed an 8.7% (2 out of 23) complication rate.

Conclusion

This study demonstrates that in patients over the age of 65, biceps tenodesis is a successful procedure when performed for biceps tendinopathy and concomitantly with other surgical procedures of the shoulder, and does not result in an increased rate of complications when compared to a group of patients under the age of 65.

Biceps Tenodesis: Biomechanical Assessment of 3 Arthroscopic Suprapectoral Techniques

Biceps tenodesis maintains the cosmetic appearance and length-tension relationship of the biceps with an associated predictable clinical outcome compared with tenotomy. Arthroscopic suprapectoral techniques are being developed to avoid the disadvantages of the open subpectoral approach. This study biomechanically compared 3 arthroscopic suprapectoral biceps tenodesis techniques performed with a suture anchor with lasso loop technique, an interference screw, and a compressive rivet. For a total of 15 randomized paired tests, 15 pairs of human cadaveric shoulders were used to test 1 technique vs another 5 times with 3 customized setups. Biomechanical testing was performed with an electromechanical testing system. The tendon was preloaded with 10 N and cyclically loaded at 0 to 40 N for 50 cycles. Load to failure testing was performed at 1 mm/s until failure occurred. The compressive rivet, interference screw, and suture anchor with lasso loop had mean load to failure of 97.1 N, 146.4 N, and 157.6 N, respectively. The difference in ultimate strength between the suture anchor with lasso loop and the compressive rivet was statistically significant (P=.04). No significant differences were found between the suture anchor with lasso loop and the interference screw (P=.93) or between the interference screw and the rivet (P=.10). When adjusted for sex, the load to failure overall among the 3 constructs was not significantly different. All 3 techniques had a different predominant mechanism of failure. The suture anchor with lasso loop showed superior load to failure compared with the compressive rivet. The minimum load to failure required to achieve clinically reliable biceps tenodesis is unknown. [Orthopedics. 2017; 40(6):e1009-e1016.].

The influence of suprapectoral arthroscopic biceps tenodesis for isolated biceps lesions on elbow flexion force and clinical outcomes

PURPOSE

To prospectively evaluate elbow flexion force, cosmetic and clinical outcome of all-arthroscopic suprapectoral biceps tenodesis for isolated biceps lesions.

METHODS

Tenodesis was performed using a 6.25-mm absorbable interference screw for intraosseous fixation. Seventeen out of 24 patients (70.8 %, median age 49.0 ± 10.1 years; 10 = male) could be included for 24 months follow-up. Elbow flexion strength in 10° and 90° elbow flexion, the upward-directed force of the upper arm in the O'Brien position, objective evaluation of a Popeye-sign deformity and validated clinical scores (CMS, SST, ASES) were assessed preoperatively, 3, 6, 12 and 24 months postoperatively.

RESULTS

Elbow flexion strength in 90° improved significantly from 12 months onwards (P = 0.001) without significant difference to the contralateral arm from 3 months postoperatively (n.s.). At 24 months, an average increase of 46.4 % (median 37.7 %) from preoperative could be seen. The dominant arm was affected in 70.6 %. All scores showed a significant improvement 3 months postoperatively: SST (P = 0.003), ASES (P = 0.006) and total CMS (P < 0.001). Three patients (17.6 %) developed a distalization of the maximum biceps circumference of more than 20 % compared to preoperative.

CONCLUSIONS

All-arthroscopic proximal suprapectoral intraosseous single-limb biceps tenodesis for the treatment of isolated biceps lesions provides good-to-excellent clinical results with significant improvement of elbow flexion strength and clinical scores and no significant difference to the unaffected contralateral arm.

LEVEL OF EVIDENCE

IV.

Subpectoral Biceps Tenodesis: Interference Screw and Cortical Button Fixation

Bicep tendon pathology often arises from chronic overuse injuries, acute trauma, or degenerative changes in the glenohumeral joint. These injuries can cause significant shoulder pain, and can greatly limit range of motion and, in turn, activities of daily living. The diagnosis of biceps pathologies can be challenging, because patients often present with nonspecific symptoms. Some bicep tendon pathologies may be treated nonoperatively; however, biceps tendon subluxation and the presence of rotator cuff or SLAP lesions require surgical management. One of the options for the treatment of bicep tendon pathology includes miniopen subpectoral biceps tenodesis. The purpose of this Technical Note is to describe in detail our preferred operative technique for miniopen subpectoral biceps tenodesis with 2 different fixation methods.

Identifying and Exposing the Proximal Biceps in Its Groove: The "Slit" Technique

Proximal biceps tendon pathology is a common source of shoulder symptoms. Thus, visualization of the entire extent of the biceps tendon is often required for both diagnostic and therapeutic purposes. Accurately recognizing the presence and extent of biceps pathology intraoperatively is made more difficult, however, due to the extra-articular location of a significant portion of the biceps tendon as it courses within the bicipital groove. Unfortunately, identification of the biceps groove in the subacromial space is often challenging due to the lack of visual and tactile landmarks. A technique that facilitates efficient and reliable bicipital groove identification and biceps tendon visualization along its entire course within the groove is presented.

Long Biceps Subpectoral Tenodesis With Suspensory Button and Bicortical Fixation

Tenodesis of the long head of the biceps (LHB) tendon has long been recognized as a valid alternative to address pathologic conditions of this tendon. However, the location and type of fixation is still a matter of discussion, because common complications associated with this procedure include failure of the repair, persistent pain, reaction to the fixation device, cosmetic deformity, and fracture. The authors describe a method of subpectoral LHB tenodesis that aims to preserve bone stock and allows a strong, easy, and reproducible type of fixation with a minimal approach. LHB tenotomy is performed arthroscopically in a standard fashion, and the tenodesis is completed with bicortical fixation in the humerus using a knotless suspensory button with an appropriate pusher originally developed for another purpose. Magnetic resonance imaging showed a safe distance between the implant and important vasculonervous structures. In the cases where subpectoral fixation is chosen, this method seems to offer additional safety as a result of the minimal amount of bone removed and the very small size of the implant.

The Effect of Concomitant Biceps Tenodesis on Reoperation Rates After Rotator Cuff Repair: A Review of a Large Private-Payer Database From 2007 to 2014

PURPOSE

To determine if reoperation rates are higher for patients who underwent isolated rotator cuff repair (RCR) than those who underwent RCR with concomitant biceps tenodesis using a large private-payer database.

METHODS

A national insurance database was queried for patients who underwent arthroscopic RCR between the years 2007 and 2014 (PearlDiver, Warsaw, IN). The Current Procedural Terminology (CPT) 29,827 (arthroscopy, shoulder, surgical; with RCR) identified RCR patients who were subdivided into 3 groups-group 1: RCR without biceps tenodesis; group 2: RCR with concomitant arthroscopic biceps tenodesis (CPT 29827 and 29,828); group 3: RCR with concomitant open biceps tenodesis (CPT 29827 and 23,430). Reoperation rates (revision RCR, subsequent biceps surgeries) and complications at 30 days, 90 days, 6 months, and 1 year were analyzed. Multivariate logistic regression was used to compare reoperations and complications between groups. Rotator cuff tear size, whether the biceps was ruptured and whether a biceps tenotomy was performed, was not available.

RESULTS

Group 1: 27,178 patients. Group 2: 4,810 patients. Group 3: 1,493 patients. More patients underwent concomitant arthroscopic than concomitant open tenodesis (P < .001). A total of 2,509 patients underwent a reoperation for RCR or biceps tenodesis within 1 year after RCR. When adjusted for age, sex, and comorbidities, no significant differences in reoperation rates at 30 days or 90 days among the 3 groups, but significantly more patients who had a tenodesis, required a reoperation compared with those who did not have a tenodesis at 6 months and 1 year (both P < .001). Urinary tract infections were more common in patients who did not have a tenodesis, whereas dislocation, nerve injury, and surgical site infection were more common in tenodesis patients.

CONCLUSIONS

Higher reoperation rates at 1 year were seen in patients who had concomitant biceps tenodesis.

LEVEL OF EVIDENCE

Level III, case-control database review study.

Patient Satisfaction After Biceps Tenotomy

Background:

Biceps tenotomy and tenodesis are frequently performed for proximal biceps lesions; however, there continues to be debate as to which method is superior. This study examined patient-reported outcomes after biceps tenotomy.

Hypothesis:

Biceps tenotomy in the setting of concomitant shoulder pathology is a reasonable option with high satisfaction rates and a low incidence of pain and cramping in middle-aged to older individuals.

Study Design:

Case series; Level of evidence, 4.

Methods:

A total of 104 patients (mean age, 63.5 years; range, 40-81 years) were evaluated at the time of surgery and at a mean follow-up of 38.4 months (range, 22-57 months). Biceps tenotomy was performed as a component of more extensive shoulder surgery in all patients. Patient satisfaction, frequency of cramping and spasms, biceps pain, weakness, and cosmetic deformity were evaluated at over 1-year follow-up.

Results:

Ninety-one percent of patients were satisfied or very satisfied with their surgical outcome, and 95% would have their surgery again. Three patients who reported being unsatisfied or very unsatisfied had either advanced glenohumeral arthritis or an irreparable rotator cuff tear. Cosmetic deformity occurred in 13% of patients. Twenty percent reported spasms and cramping in their biceps, and 19% reported some biceps pain; however, frequency of spasms and cramping was typically once weekly, and biceps pain was reported as severe or very severe in only 2 patients. Subjective biceps weakness was reported in 17% of patients. Age had no effect on outcome measures, and female sex was associated with less limitation and greater satisfaction after tenotomy compared with men.

Conclusion:

Our results indicate that patient-reported downsides to biceps tenotomy were usually mild and/or infrequent and did not affect patient satisfaction. We conclude that biceps tenotomy is a viable option that can lead to a high rate of patient satisfaction and outcomes in middle-aged to older individuals undergoing shoulder surgery with biceps pathology.

A Simple, All-Arthroscopic, Knotless Suture Lasso Loop Technique for Suprapectoral Biceps Tenodesis

A variety of pathology of the long head of the biceps tendon can contribute to anterior shoulder pain in adults that can be managed with either arthroscopic tenotomy or tenodesis when conservative treatment fails. Biceps deformity or the Popeye sign is a major concern in patients after tenotomy. Biceps tenodesis can be performed in a variety of ways with different sized anchors and at different locations (suprapectoral or subpectoral). Several studies have shown that patient outcomes and complication rates are similar between all-arthroscopic suprapectoral biceps tenodesis and open subpectoral biceps tenodesis. We describe a simple, knotless, arthroscopic intra-articular biceps tenodesis technique using a 1.5-mm LabralTape lasso loop technique and a 2.9-mm PushLock anchor.

All-Arthroscopic Suprapectoral Versus Open Subpectoral Tenodesis of the Long Head of the Biceps Brachii Without the Use of Interference Screws

PURPOSE

To compare patient-reported outcomes and healing rates after open subpectoral and all-arthroscopic suprapectoral biceps tenodesis without the use of interference screws in patients with more than 2 years of follow-up.

METHODS

Patients with at least 2 years of follow-up who underwent open subpectoral biceps tenodesis or all-arthroscopic suprapectoral biceps tenodesis without concomitant rotator cuff repair, labral repair, or Mumford procedure were considered for enrollment in the study. They were evaluated for visual analog scale (VAS), American Shoulder and Elbow Surgeons (ASES) score, and satisfaction with function and biceps contour. Ultrasonography was performed to evaluate the integrity of the tenodesis site and measure biceps muscle diameters on each arm.

RESULTS

Forty-nine patients were eligible for our study and of these, 38 were able to participate. Twenty-three patients had open subpectoral biceps tenodesis and 15 received all-arthroscopic suprapectoral biceps tenodesis. The average follow-up time was 4.5 years (range 2-9.1 years). There were no significant differences in anterior shoulder pain VAS, ASES scores, or satisfaction rates. The average anterior shoulder VAS was 0.7 ± 1.1 for the open group and 0.9 ± 1.8 for the arthroscopic group (P = .74). The mean ASES score for the open group was 90.6 ± 11.4 and 91.4 ± 13.9 for the arthroscopic group (P = .69). All patients had an intact tenodesis site on ultrasonography and the ratio of operative to nonoperative biceps diameters was 100.2% ± 12.8% for the open group and 99.1% ± 10.8% for the arthroscopic group (P = .66). There were no infections and no brachial plexus injuries in either group.

CONCLUSIONS

Open subpectoral biceps tenodesis and all-arthroscopic suprapectoral biceps tenodesis are both successful surgeries with consistently positive outcomes. Tenodesis can be performed in either location without interference screw fixation with durable, reliable results.

LEVEL OF EVIDENCE

Level III, retrospective comparative trial.

The "3-Pack" Examination Is Critical for Comprehensive Evaluation of the Biceps-Labrum Complex and the Bicipital Tunnel: A Prospective Study

PURPOSE

To determine the diagnostic value of the 3-Pack examination for biceps-labrum complex (BLC) disease, assess interobserver reliability, and generate an evidence-based diagnostic and therapeutic algorithm.

METHODS

A total of 145 consecutive patients were enrolled in this prospective comparative study. The study included 116 chronically symptomatic patients indicated for arthroscopic subdeltoid transfer of the long head of the biceps tendon to the conjoint tendon and 29 asymptomatic comparison subjects. Each patient underwent examination that included the 3-Pack (active compression test [O'Brien sign], throwing test, and bicipital tunnel palpation) and traditional examination (Speed test; Yergason test; full can test; empty can test) in a blinded, randomized fashion by 3 investigators. Intraoperative BLC disease was prospectively categorized by location (inside, junctional, or bicipital tunnel).

RESULTS

3-Pack tests were highly sensitive (73% to 98%), but less specific (46% to 79%) for BLC in all 3 locations than some of the traditional tests, which were less sensitive (20% to 67%), but more specific (83% to 100%) for BLC disease in all 3 locations. With regard to hidden bicipital tunnel lesions, palpation and O'Brien sign were highly sensitive (97.8% and 95.7% respectively) and revealed high negative predictive value (NPV, 96.4% and 92.6% respectively). Speed and Yergason tests, conversely, were poorly sensitive but had high specificities (86.7% and 97.9%, respectively) and positive predictive value (76% and 92.3%, respectively). Inter-rater reliabilities were substantial to almost perfect for the 3-Pack examination (kappa 70% to 85%) and fair to moderate for the 4 traditional examinations (kappa 25% to 56%).

CONCLUSIONS

The 3-Pack has excellent inter-rater reliability, sensitivity, and NPV and is a critical screening tool for BLC disease in all zones. Hidden extra-articular bicipital tunnel disease can reliably be excluded based on negative tenderness to palpation or a negative O'Brien sign (NPV 93% to 96%).

LEVEL OF EVIDENCE

Level III, case control study.