All-arthroscopic suprapectoral versus open subpectoral tenodesis of the long head of the biceps brachii

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.

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.

Arthroscopic Transtendinous Biceps Tenodesis With All-Suture Anchor

There are several methods for long head of the biceps (LHB) tenodesis, yet the optimal option is still debatable. Here we introduce a technique for arthroscopic suprapectoral biceps tenodesis with an all-suture anchor, the transtendinous biceps tenodesis technique. The LHB tenodesis is performed by using the Y-Knot anchor (1.3-mm). A standard suprapectoral approach is used for the tenodesis. A 1.3-mm drill bit is used to drill through the midportion of the biceps tendon and underlying bone to make a pilot hole. Next, the Y-Knot anchor is passed through the tendon and anchored on the underlying bone. A wrapping suture technique is then used to wrap around, tension, and secure the LHB tendon with the aid of a shuttling polydioxanone suture. The construct is fixed by tying down both suture limbs in a nonsliding fashion. This Technical Note describes an alternative method for all-arthroscopic suprapectoral biceps tenodesis using an all-suture anchor with a small diameter to minimize trauma to the tendon.

Subpectoral Biceps Tenodesis for Tenosynovitis of the Long Head of the Biceps in Active Patients Younger Than 45 Years Old

PURPOSE

The objective of this study was to assess the outcomes after subpectoral biceps tenodesis (BT) for long head of the biceps (LHB) tenosynovitis in active patients <45 years old.

METHODS

This was an Institutional Review Board-approved, retrospective outcomes study with prospectively collected data. Patients treated with subpectoral BT were included if they met the following criteria: age <45 years, anterior shoulder pain with arthroscopically confirmed LHB tenosynovitis, no concomitant procedures other than debridement and decompression procedures, and minimum 2 years out from surgery. Patients were excluded from analysis if they refused participation. The American Shoulder and Elbow Surgeons (ASES), Short Form-12, Quick Disabilities of the Arm, Shoulder and Hand, Single Assessment Numeric Evaluation, and pain scores as well as sports participation preoperatively and at a minimum of 2 years postoperatively were obtained. Pre- and postoperative scores were compared using paired samples t-test and Wilcoxon signed-rank test.

RESULTS

Thirty patients met the inclusion criteria. Two of these patients refused to participate in follow-up and were excluded from analysis. Of the remaining 28 patients (17 male, 11 female; 37.0 ± 8.0 years), minimum 2-year outcomes were available for 24 (13 males, 11 females: 37.7 ± 8.2 years; 85.7%). Mean follow-up was 3.1 years (range, 2.0 to 7.3 years). There were significant improvements in all outcome measures including ASES score (P < .001), with a postoperative mean of 95.8 ± 7.8, visual analog scale "pain today" (P < .001), and pain affecting activities of daily living (P < .001). Seventeen of 20 (85%) patients who answered the question about postoperative sport participation were able to return to sport. Mean patient satisfaction was 9.2/10 (standard deviation, +1.7). There were no postoperative complications such as Popeye deformity or cramping. There were no clinical failures.

CONCLUSIONS

Subpectoral BT is an excellent treatment option for active patients <45 years old with LHB tenosynovitis and chronic anterior shoulder pain, resulting in decreased pain, improved function, high satisfaction, and improved quality of life.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

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.

Relationship between subscapularis tears and injuries to the biceps pulley

PURPOSE

The purpose of this study was to analyse the relationship between long head of the biceps brachii (LHBT) lesions and subscapularis tears. The hypothesis was that a bicipital pulley might remain intact, even in the case of a subscapularis tear.

METHODS

Between 2010 and 2011, all patients who had a primary arthroscopic repair of a subscapularis tear were potentially included in this prospective study. The outcome of interest was the prevalence and type of arthroscopic lesions of the LHBT and bicipital pulley. Furthermore, the supposed pathomechanics of injury and the treatment proposed (conservative, pulley repair, tenodesis, tenotomy, etc.) was recorded. The following baseline characteristics were assessed: age, sex, shoulder side, and limb dominance.

RESULTS

Of the 218 patients, the superior glenohumeral ligament/coracohumeral ligament (SGHL/CHL) complex was normal in 54 patients (25%), stretched in 84 patients (39%), and absent in 77 patients (35%). Below the SGHL/CHL complex in the bicipital groove, the medial wall of the LHBT sheath was normal in 25%, partially torn in 39%, and completely torn in 35%. In 25 of the 218 patients (11%), a pathologic LHBT with an intact SGHL/CHL complex was observed. In these cases, the medial wall of the bicipital sheath was torn in 92%.

CONCLUSIONS

The biceps pulley system, including the SGHL/CHL complex and subscapularis tendon, merits recognition as an important anatomical structure, and its lesions contribute to shoulder pathology. The subscapularis tendon is very important for the stability of the LHBT and should be included in the pulley system. In cases of a tear associated with a lesion of the SGHL/CHL complex, the LHBT is nearly always unstable and pathologic.

LEVEL OF EVIDENCE

II.

Arthroscopic Suprapectoral and Open Subpectoral Biceps Tenodesis: Radiographic Characteristics

PURPOSE

To provide a detailed account of the location of the long head of the biceps (LHB) tenodesis tunnels using an all-arthroscopic suprapectoral technique in a prospective group of patients. These patients were then compared with a retrospective group of open subpectoral tenodesis patients of similar characteristics.

METHODS

Postoperative radiographs from a prospective group of all-arthroscopic suprapectoral LHB tenodeses were compared with a retrospective group of open subpectoral tenodeses. Digital anteroposterior images were used to measure distances from clinically pertinent radiographic landmarks to tenodesis tunnel sites.

RESULTS

Forty patients (20 all-arthroscopic, 20 open) met the inclusion criteria. The inferior border of the bicipital groove was located a mean distance of 33.7 ± 6.9 mm from the top of the humeral head. The mean distance measured in the open group was approximately 28 mm (P < .001) distal compared with the arthroscopic group. The humeral diameter was 7.5 ± 5.4 mm narrower at the subpectoral tenodesis site (P < .001). All 20 patients in the open subpectoral group had tenodesis tunnels placed distal to the bicipital groove compared with 17 of 20 patients (85%) in the all-arthroscopic group. There were 2 cases of lateral wall cortical reaming during subpectoral tenodesis but no periprosthetic humeral fractures. There were 2 cases of bicortical reaming during the all-arthroscopic tenodesis with no known complications.

CONCLUSIONS

The location of biceps tenodesis significantly differs between all-arthroscopic suprapectoral and open subpectoral techniques, and the open subpectoral method achieves fixation in a significantly narrower region of the humerus.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Outcomes following long head of biceps tendon tenodesis

Lesions of the proximal long head of the biceps tendon (LHB) have been considered as a major cause of shoulder pain and dysfunction. The role of the LHB in causing pain has been a source of controversy for many years, and extensive literature is available discussing anatomy, function, pathology, and most importantly appropriate treatment. Despite this, there is a lack of consensus in the literature regarding the management of biceps-related pathology. Biceps tenotomy and tenodesis are common surgical treatment options when dealing with LHB-related pathology. In this review, a brief discussion on surgical options is provided while focusing on the different options for biceps tenodesis including outcomes and complications.

A 70° Arthroscope Significantly Improves Visualization of the Bicipital Groove in the Lateral Decubitus Position

PURPOSE

The purpose of this study was to quantify the length of the bicipital groove viewable with a 70° arthroscope and to compare this distance visualized with use of a 30° arthroscope in both cadavers and living subjects.

METHODS

Diagnostic glenohumeral arthroscopy in the lateral decubitus position was performed on 10 fresh-frozen cadaveric shoulders from a posterior portal. Using 70° and 30° arthroscopes, the distalmost viewable portion of the bicipital groove was percutaneously marked. Dissection of each specimen was then performed, and the distances between the articular margins of the humeral head to each marked portion of bicipital groove were recorded. Subsequently, a similar technique was used to measure the visible length of the bicipital groove in a series of 11 patients at the time of diagnostic glenohumeral arthroscopy performed in the lateral decubitus position using 70° and 30° arthroscopes. Descriptive statistics were used for continuous data. Means were compared with a Mann-Whitney test. Statistical significance was set at P ≤ .05.

RESULTS

The cadaveric analysis revealed a significant increase in the amount of bicipital groove visualized with the 70° arthroscope versus that visualized with the 30° arthroscope (18.0 ± 6.9 mm v 11 ± 4.7 mm, P = .01). In similar fashion, the results of the in vivo analysis showed that the 70° arthroscope allowed for significantly more visualization of the bicipital groove than the 30° arthroscope (26.3 ± 6.2 mm v 14 ± 4.7 mm, P = .025).

CONCLUSIONS

The use of a 70° arthroscope significantly increases the length of bicipital groove visualized during glenohumeral arthroscopy in the lateral decubitus position compared with that of the 30° arthroscope in both cadavers and living subjects.

CLINICAL RELEVANCE

Routine use of a 70° arthroscope significantly improves visualization of the bicipital groove and all relevant intra-articular structures compared with that of a 30° arthroscope during diagnostic glenohumeral arthroscopy performed in the lateral decubitus position.

Biomechanical Comparison of All-Suture Anchor Fixation and Interference Screw Technique for Subpectoral Biceps Tenodesis

PURPOSE

To compare the biomechanical characteristics of the subpectoral Y-knot all-suture anchor fixation with those of the interference screw technique.

METHODS

Sixteen fresh-frozen human cadaveric shoulders with a mean age of 67.6 ± 5.8 years (range, 52 to 74 years) were studied. The specimens were randomly grouped into 2 experimental biceps tenodesis groups (n = 8): Y-knot all-suture anchor or interference screw. The specimens were cyclically tested to failure by applying tensile forces parallel to the longitudinal axis of the humerus. A preload of 5 N was applied for 2 minutes prior to cyclic loading for 500 cycles from 5 to 70 N at 1 Hz; subsequently, a load-to-failure test at 1 mm/s was performed. The ultimate failure load, stiffness, displacement at cyclic and failure loading, and mode of failure were recorded.

RESULTS

The all-suture anchor technique displayed values of ultimate failure load and stiffness comparable to that of the interference screw technique. The displacement at cyclic and failure loading of the all-suture anchor trials were significantly greater than the interference screw (P = .0002). The all-suture anchor specimens experienced anchor pullout and tendon tear equally during the trials, whereas the interference screw group experienced tendon tear in most of the cases and screw pullout in 2 trials.

CONCLUSIONS

The Y-knot all-suture anchor fixation provides equivalent ultimate failure load and stiffness when compared with the interference screw technique in tenodesis of the proximal biceps tendon from a subpectoral approach. However, the interference screw technique demonstrates significantly less displacement in response to cyclic and failure loading.

CLINICAL RELEVANCE

The all-suture anchor fixation is an alternative technique for subpectoral biceps tenodesis even at greater displacement when compared with the interference screw fixation during cyclic and failure loading.

Qualitative Assessment and Quantitative Analysis of the Long Head of the Biceps Tendon in Relation to the Pectoralis Major Tendon Humeral Insertion: An Anatomic Study

PURPOSE

To qualitatively assess and to quantitatively analyze the long head of the biceps tendon (LHBT) in the region of the pectoralis major (PM).

METHODS

From 11 fresh cadaveric donors, 20 cadaveric shoulders without operative scars were dissected-mean age, 76.9 years (range, 61 to 93 years); male, 75%; left-sided, 55%; mean height, 67.8 inches (range, 61 to 71 inches); mean weight, 148.1 pounds (range, 106 to 176 pounds). Two specimens with discovered ruptures were excluded. The LHBT circumference was measured at the anterior edge of supraspinatus, suprapectorally, midpectorally, and subpectorally. The muscle was then removed from the LHBT and the circumference was again measured at the supra-, mid-, and subpectoral levels. These data were used to calculate the area of the tendon. All measurements were performed by 2 independent observers. Statistical analysis was performed to assess reliability of data and the difference between serial measurements.

RESULTS

The mean calculated percentage tendon decreased from 86.7% at the superior edge of the PM to 49.8% at the midpoint of the PM and to 17.5% at the inferior edge of the PM.

CONCLUSIONS

Distal to the PM, the LHBT was composed of a small percentage of tendon to muscle, which may have implications for the mechanical strength of fixation of tenodesis. The anatomic location of the musculotendinous junction of the LHBT began proximal to the superior edge of the PM tendon, which implies that restoration of anatomic tensioning may require a more proximal docking site than previously described. Tenodesis performed between the midpoint of the PM insertion and more distal points involves a significant portion of muscle, which may not be optimal.

CLINICAL RELEVANCE

Tenodesis performed between the midpoint of the PM insertion and more distal points involves a significant portion of muscle, which may affect the mechanical strength or optimal choice of fixation location.

Biceps Lesion Associated With Rotator Cuff Tears: Open Subpectoral and Arthroscopic Intracuff Tenodesis

Background:

Various tenodesis methods are being used for long head of the biceps tendon lesions. However, there is no consensus on the most appropriate surgical method.

Hypothesis:

There are significant differences in incidence of cosmetic deformity and persistent bicipital pain between open subpectoral and arthroscopic intracuff tenodesis groups.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

This study included 72 patients who underwent biceps tenodesis and rotator cuff repair between January 2009 and May 2014 and who were followed for at least 1 year. Open subpectoral tenodesis was performed in 39 patients (group A), and arthroscopic intracuff tenodesis was performed in 33 patients (group B).

Results:

In group A, the mean visual analog scale (VAS) score for pain during motion and mean University of California, Los Angeles (UCLA) and Constant scores significantly improved from 4.6, 18.6, and 64.5 preoperatively to 1.9, 30.5, and 86.5 at last follow-up, respectively (P < .001 for all). In group B, these scores significantly improved from 5.1, 17.6, and 62.9 preoperatively to 1.8, 31.5, and 85.9 at last follow-up, respectively (P < .001 for all). Popeye deformity was noted in 2 (5.2%) patients from group A and 5 (15.6%) patients from group B (P = .231). Additionally, persistent bicipital tenderness was noted in 1 (2.6%) patient from group A and 8 (24.2%) patients from group B (P = .012).

Conclusion:

Both open subpectoral tenodesis and arthroscopic intracuff tenodesis show good clinical outcomes for long head of the biceps tendon lesions. However, open subpectoral tenodesis may be more appropriate, considering the low incidence of Popeye deformity and tenderness.

Safety and efficacy of arthroscopy in the setting of shoulder arthroplasty

Shoulder arthroplasty has become a reliable and reproducible method of treating a range of shoulder pathologies including fractures, osteoarthritis, and rotator cuff arthropathy. Although most patients experience favorable outcomes from shoulder arthroplasty, some patients suffer from persistent symptoms post-arthroplasty and it is these patients who present a unique diagnostic and therapeutic challenge. The role of arthroscopy in assessing and treating patients with symptomatic prosthetic joints elsewhere in the body has been established in recent literature. However, the range of pathology that can affect a prosthetic shoulder is distinct from the knee or the hip and requires careful and considered assessment if an accurate diagnosis is to be made. When used alongside other investigations in a comprehensive assessment protocol, arthroscopy can play an important role in the diagnosis and treatment of the problematic shoulder arthroplasty.

Systematic Review of Biceps Tenodesis: Arthroscopic Versus Open

PURPOSE

We present a systematic review of the recent literature regarding the use of arthroscopic and open methods of tenodesis for lesions of the long head of the biceps brachii and present an analysis of the subjective and objective outcomes after these 2 procedures.

METHODS

PubMed was carefully reviewed for suitable articles relating to biceps tenodesis, both open and arthroscopic. We included studies reporting on the clinical outcomes of these 2 procedures that were of Level I to IV evidence and were published in the English language. The primary clinical outcomes for each study were determined, normalized, and reported as the percentage of good or excellent results versus poor results based on the outcome scores and criteria laid out by the authors in each of the studies. The exclusion criteria included studies in which biceps tenodesis was performed in patients with concomitant rotator cuff repairs, nonhuman studies, and biomechanical studies.

RESULTS

A total of 16 studies met our inclusion criteria. Among all studies, a total of 205 arthroscopic tenodesis procedures and a total of 271 open tenodesis procedures were performed. Among the 271 open tenodesis patients, 98% had a good or excellent outcome, with a poor outcome in 5 patients (2%). Among the 205 patients who underwent arthroscopic tenodesis, 98% had a good or excellent outcome, with a poor outcome in 5 patients (2%).

CONCLUSIONS

Both open and arthroscopic biceps tenodesis provided satisfactory outcomes in most patients, and there were no identifiable differences in this review.

Editorial Commentary: Open Versus Arthroscopic Biceps Tenodesis--You Choose

In a Level IV evidence systematic review of 16 studies comparing arthroscopic and open biceps tenodesis, both techniques showed good or excellent short-term subjective and objective clinical outcomes in 98% of subjects. Ultimately, technique selection may be based on surgeon preference. In open tenodesis, one should avoid vigorous medial retraction to mitigate the risk of nerve injury.

Biceps tenodesis (long head): arthroscopic keyhole technique versus arthroscopic interference screw: a prospective comparative clinical and radiographic marker study

PURPOSE

The long head biceps tenodesis (LHBT) is an alternative to tenotomy in order to prevent Popeye sign.Biomechanical studies showed that interference screw(IFS) was the strongest fixation but there might be complications and cost. What's more, the analyses of tenodesis failures are undervalued because they only take visible deformations of the arm into account. The purpose of this study was to compare a modified arthroscopic "keyhole" LHBT (modified @KH) with an arthroscopic IFS LHBT(@IFS) using an objective method. We hypothesized that modified @KH gave similar clinical outcomes as @IFS without its hassles or drawbacks.

METHODS

We present a 12-month prospective comparative study (modified @KH versus @IFS) performed by two experienced orthopedic surgeons. Modified @KH was performed on one hundred and nine patients versus @IFS that was performed on one hundred and two. A radiopaque marker was placed into the tendon. The review was conducted in the sixth month with clinical examination and plain standard X-ray to objectify the potential migration of the marker.

RESULTS

Modified @KH showed 2.4 % visible deformity without any Popeye sign but 3.4 % radiographic metallic marker migrations. No complications were noted. @IFS showed 5.8 % visible deformity with 2.9 % Popeye sign and with 10.3 % radiographic metallic marker migrations;pain at tenodesis location was noted in 2 %. P value (0.13) indicates that there were no statistically significant differences.

CONCLUSION

We confirm the hypothesis that the modified@KH gives clinical and radiographic outcomes at least similar to @IFS without any complications and cost. The establishment of the radiopaque marker allows us to know the exact number of failures.Level of evidence Consecutive prospective comparative clinical, Level II-1 studies.

Biceps Tenotomy Versus Tenodesis

Long head biceps tendon is a common cause of anterior shoulder pain. Failure of conservative treatment may warrant surgical intervention. Surgical treatment involves long head biceps tenotomy or tenodesis. Several different techniques have been described for biceps tenodesis, including arthroscopic versus open and suprapectoral versus subpectoral. Most studies comparing tenodesis to tenotomy are limited by the level of evidence and confounding factors, such as concomitant rotator cuff tear. Many studies demonstrate similar outcomes for both procedures. Surgeon preference is likely more influential in choosing between tenotomy and tenodesis. Higher-powered studies are necessary to elucidate any differences in outcomes if present.