Diagnostic glenohumeral arthroscopy fails to fully evaluate the biceps-labral complex

Arthroscopic Subdeltoid Transfer of the Long Head of the Biceps Tendon to the Conjoint Tendon

Surgical intervention is often recommended for refractory pathology affecting the biceps-labrum complex. Tenodesis of the long head of the biceps tendon (LHBT) is a widely accepted treatment modality; however, the optimal technique remains elusive. Arthroscopic subdeltoid transfer of the LHBT to the conjoint tendon, as described in this technical note, continues to demonstrate excellent clinical results. Its advantages include soft tissue-to-soft tissue healing, an advantageous biomechanical construct, and comprehensive evaluation and decompression of the LHBT including the extra-articular bicipital tunnel. The primary limitation of this procedure is the perceived learning curve for safe navigation within the subdeltoid space.

Radiographic evaluation of the bicipital groove morphology does not predict intraarticular changes in the long head of biceps tendon

INTRODUCTION AND OBJECTIVES

This study aimed to examine the clinical utility of the radiographic evaluation of the bicipital groove in predicting long head of biceps tendon (LHBT) pathology.

MATERIAL AND METHODS

A prospective study was conducted, and sixty consecutive patients proposed to shoulder arthroscopic surgery were selected. Before surgery, a radiographic evaluation was performed with a supine and a Fisk radiograph. Most supine radiographs (>75%) were non-interpretable and were excluded from the study. As some Fisk radiographs (26.7%) were also non-interpretable, that left 44 interpretable radiographs in the study. These were measured for medial opening angle, total opening angle, width and depth of the bicipital groove. The radiographic measurements and the presence of LHBT pathology, as assessed at arthroscopy, were correlated.

RESULTS

Radiographic evaluation of the bicipital groove showed a mean medial opening angle of 53 ± 15° (23-90), a mean total opening angle of 80 ± 26° (30-135), a mean width of 10.3 ± 2.5 mm (6-19) and a mean depth of 4.1 ± 1.5 mm (1-8). Men had higher medial opening angle (60 vs 50°, p = 0.044) and wider grooves (11.9 vs 9.7 mm, p = 0.019). Twenty-five patients (56.8%) were found to have an abnormal LHBT. No correlation was found between the radiographic measurements and LHBT pathology. Only age was correlated with a LHBT lesion (61.8 vs 46.3 years, p < 0.001).

CONCLUSIONS

Our results show that there is no correlation between radiographic morphologic evaluation of the bicipital groove and LHBT pathology.

Revision Subpectoral Biceps Tenodesis Demonstrates a High Patient Satisfaction and Good Functional Outcomes

Purpose

To clinically evaluate a subset of patients who underwent a revision subpectoral biceps tenodesis for a clinically failed proximal biceps tenodesis.

Methods

This is a retrospective case series of patients with at least 2-year follow-up who had undergone a revision biceps tenodesis after clinical failure of a proximal biceps tenodesis between January 2008 and February 2020 by a single surgeon. Patients who underwent concomitant procedures, such as revision cuff repair, were excluded. Patients with a minimum of 2 years duration status postrevision subpectoral tenodesis were contacted for informed consent and outcome data, which included Simple Shoulder Test, American Shoulder and Elbow Surgeons score, visual analog scale for pain, and subjective reporting of arm weakness and satisfaction.

Results

Fourteen patients were initially identified as meeting inclusion criteria with a minimum 2-year follow-up achieved for 11 of 14 patients (78.5% follow-up). The mean follow-up time was 8.1 years (range, 2.7-14.8 years). After the primary biceps tenodesis, a mean of 8.0 ± 9.6 months passed before the revision subpectoral biceps tenodesis was performed. The average postoperative active forward elevation and adducted external rotation were 159 ± 7° and 47 ± 17°, respectively. The mean ± standard deviation (range) follow-up American Shoulder and Elbow Surgeons score was 79 ± 23 (30-100), Simple Shoulder Test was 11 ± 2 (7-12), and visual analog scale for pain was 2.6 ± 2.8 (0-9). All 11 patients reported being satisfied with their operation and would elect to have the operation again.

Conclusions

Revision subpectoral biceps tenodesis is a viable procedure for addressing patients with persistent pain following initial proximal biceps tenodesis. Although some persistent pain is common, revision subpectoral biceps tenodesis demonstrates a high patient satisfaction and good functional outcomes.

Level of Evidence

Level IV, therapeutic case series.

A preliminary attempt to use radiomic features in the diagnosis of extra-articular long head biceps tendinitis

BACKGROUND

This study aims to present a radiomic application in diagnosing the long head of biceps (LHB) tendinitis. Moreover, we evaluated whether machine learning-derived radiomic features recognize LHB tendinitis.

PATIENTS AND METHODS

A total of 170 patients were reviewed. All LHB tendinitis patients were diagnosed under arthroscopy. Radiomic features were extracted from preoperative magnetic resonance imaging (MRI), and the input dataset was divided into a training set and a test set. For feature selection, the t test and least absolute shrinkage and selection operator (LASSO) methods were used, and random forest (RF) and support vector machine (SVM) were used as machine learning classifiers. The sensitivity, specificity, accuracy, and area under the curve (AUC) of each model's receiver operating characteristic (ROC) curves were calculated to evaluate model performance.

RESULTS

In total, 851 radiomic features were extracted, with 109 radiomic features extracted using a t test and 20 radiomic features extracted using the LASSO method. The random forest classifier shows the highest sensitivity, specificity, accuracy, and AUC (0.52, 0.92, 0.73, and 0.72).

CONCLUSION

The classifier contract by 20 radiomic features demonstrated a good ability to predict extra-articular LHB tendinitis.However because of poor segmentation reliability, the value of Radiomic in LHB tendinitis still needs to be further explored.

The long head of biceps at the shoulder: a scoping review

BACKGROUND

This review aimed to explore the available literature to update our understanding of the long head of biceps (LHB) at the shoulder. Synthesise our findings to identify emergent themes and knowledge gaps to inform future research and management directions.

METHODS

PubMed, Embase, Cinahl, SportDiscus, CENTRAL, and Web of Science were searched from inception to 31st December 2021. Articles were included if they referenced adult participants > 18 years of age and were written in English.

RESULTS

214 articles were included in the final analysis, and results were categorised into six emergent themes: (1) Anatomy - Normal anatomical variation of the biceps from aberrant origins, third and fourth accessory heads, and an absence of the LHB tendon (LHBT) are not necessarily benign, with shoulder pain and instability a commonly reported theme. (2) Function - Bicep's role in glenohumeral elevation and stability in healthy shoulders is minimal. In contrast, LHB has a more significant role in shoulder stability and humeral head depression in subjects with rotator cuff failure or an absent LHBT. (3) Pathology - There is an association between LHB tendinopathy, rotator cuff disease, LHBT instability and occult rotator cuff tears. Early recruitment and hyperactivity of the LHB in subjects with symptomatic rotator cuff tears and instability suggest a potential compensatory role. (4) Assessment - The limited diagnostic utility of special orthopaedic tests in assessing LHBT pathology was a consistent theme. The utility of magnetic resonance imaging and ultrasound to identify full-thickness tendon tears and instability of the LHBT was moderate to high. However, the utility of clinical tests and imaging may be underestimated due to arthroscopy's limitations in fully visualising the proximal LHBT. (5) Non-Surgical Management - Ultrasound-guided injections into the biceps sheath show greater accuracy and patient outcomes than blinded injections; however, the entry of injectate into the intraarticular glenohumeral joint may have unwanted complications. (6) Surgical management - For the surgical management of biceps pathology with or without rotator cuff pathology, both biceps tenodesis and tenotomy report similar improvements in pain without any significant adverse effect on strength or function. Tenodesis favoured higher overall constant scores and a lower incidence of Popeye deformity and cramping arm pain, with tenotomy trending to be more cost and time effective. For patients with a healthy LHBT, rotator cuff repair with adjunctive tenodesis or tenotomy fails to provide additional clinical improvements compared to rotator cuff repair in isolation.

CONCLUSIONS

The scoping review highlights the variability of biceps anatomy, which is not necessarily benign and suggests a minimal role of the LHB in shoulder elevation and stability in healthy individuals. In contrast, individuals with rotator cuff tears experience proximal humeral migration and demonstrate hyperactivity of the LHB, suggesting a potential compensation role. The observed prevalence of LHBT pathology with rotator cuff tears is well established; however, the cause-and-effect relationship between LHBT pathology and rotator cuff disease is undetermined. The diagnostic utility of clinical tests and imaging to exclude LHBT pathology may be understated due to the limitations of arthroscopy to visualise the proximal LHBT fully. Rehabilitation programs for the LHB are understudied. Similar post-surgical clinical outcomes are observed for tenodesis and tenotomy for biceps and rotator cuff-related shoulder pain. Subjects undergoing biceps tenodesis are less likely to have cramping arm pain and a Popeye deformity than patients undergoing biceps tenotomy. The significance of routine surgical removal of the LHBT and sequelae on rotator cuff tear progression to failure and long-term shoulder function is unknown, and further research is required.

PRE-REGISTRATION

OSF: https://osf.io/erh9m.

Nonoperative Treatment of the Biceps-Labral Complex

The long head of the biceps and superior labrum should be evaluated as an interdependent functional unit. A focused patient history and physical examination including multiple provocative tests should be performed alongside advanced imaging studies to obtain an accurate diagnosis. Nonoperative treatment modalities including nonsteroidal anti-inflammatory drugs, glucocorticoid injections, and a standardized physical therapy regimen should be exhausted before operative intervention. Significant improvements in pain, functional outcomes, and quality of life are achieved in patients treated nonoperatively. Although these outcomes are less consistent for overhead athletes, return to play and performance metrics seem comparable to those who undergo surgery.

Arthroscopic Suprapectoral Biceps Tenodesis: The Best of Both Worlds

Biceps tendinopathy and superior labrum anterior posterior lesions are a common source of shoulder pain and disability and can be effectively treated with biceps tenodesis. There are a variety of open and arthroscopic tenodesis techniques, but no one technique has demonstrated superiority. Arthroscopic techniques often disregard the extra-articular portions of the biceps tendon as a potential source of pain. Open techniques address this concern; however, they can be associated with wound complications, increased blood loss, nerve injury, and disruptions to surgical workflow. Here, we describe an all arthroscopic tenodesis technique at the suprapectoral zone of the tendon. This method addresses extra-articular sources of pain, while limiting the potential pitfalls of open surgery.

Improvement in long head of biceps function and lower rate of biceps deformities after subpectoral tenodesis with cortical button and interference screw vs. arthroscopic tenotomy: a 4-year follow-up

Background

This study aimed to evaluate clinical, cosmetic, and strength midterm outcomes in arthroscopic biceps tenotomy and subpectoral biceps tenodesis using bicortical endobutton and interference screw.

Methods

In this retrospective study, inclusion criteria were long head of the biceps (LHB) pathologies treated either with tenotomy or an additional tenodesis. Postoperative assessment included Long Head of Biceps Score (LHBS), age-adjusted Constant-Murley Score, and Subjective Shoulder Value. Elbow flexion and forearm supination strength were measured. The presence of Popeye sign, cramps, and tenderness over the bicipital grove was evaluated. Statistical analysis of continuous variables without normal distribution was performed using Mann-Whitney U test. Grouped analysis was performed using 2-way analysis of variance. Binominal data were analyzed using chi-square test.

Results

A total of 73 patients with a mean age of 63.1 ± 9.6 years and a mean follow-up of 4.2 ± 0.5 years were included. Tenotomy was performed in 34 and tenodesis in 39 patients. Tenodesis group displayed a significantly higher LHB score (P = .0006), but no significant differences were detected for the age-adjusted Constant-Murley Score and Subjective Shoulder Value. Tenodesis group showed a significantly lower rate of Popeye deformities (P = .0007) and tenderness over the bicipital groove (P = .004). Patients from the tenotomy group with biceps deformity showed a significantly higher mean contralateral supination strength (P = .002) but no significant difference in contralateral elbow flexion compared with patients without biceps deformity. There was one (1.4%) complication in the tenotomy group (postoperative shoulder stiffness).

Conclusion

Both techniques resulted in comparable outcome scores on preselected patients, with tenodesis leading to better LHB function. Tenodesis did not improve elbow flexion and forearm supination strength beyond the tenotomy; however, it reduced the frequency of biceps deformities and tenderness over the bicipital groove. Patients with a strong contralateral forearm supination strength could be at risk of developing a biceps deformity after tenotomy.

Flexion-extension-supination test compared to arthroscopic findings of biceps long head pathology: A physical examination that reflect anatomical evolution of human shoulder girdle

The accuracy of physical examination for diagnosing lesions of the long head of the biceps tendon (LHBT) remains unsatisfactory. The purpose of this study was to describe a new diagnostic test, the Flexion-Extension-Supination (FES) test for diagnosing lesions of the long head of biceps tendon. A prospective study of 162 patients was performed to evaluate the diagnostic value of FES test. All the participants were evaluated on the basis of their clinical presentation, physical examination (FES test), radiologic findings and arthroscopic examination. Shoulder arthroscopy findings were used as the gold standard. To reduce the omission of the hidden lesion, LHBT was checked at the intra- and the extraarticular side via arthroscopic examination. Surgical findings related to biceps pathology were as follows: rotator cuff tears, 89.5% (145/162); subacromial impingement, 8.6% (14/162); and biceps tendinitis, 1.9% (3/162). The prevalence of biceps pathology was 77.2% (125/162) of all arthroscopic procedures. No significant differences for LHBT lesions were observed between the FES test and the arthroscopic findings (P = .850). The interrater reliability of the FES test was 0.747. After excluding inconclusive results between examiners, the sensitivity, specificity, positive predictive value, and negative predictive value of the FES test were 87.9%, 66.7%, 82.9%, and 63.2%, respectively. Positive and negative likelihood ratios were 2.67 and 0.18, respectively. The maneuvers of the FES test irritate intra- and extraarticular lesion of LHBT. The FES test is a reproducible and reliable test that can be used during physical examinations to evaluate patients with LHBT lesions.

3D imaging has good specificity but poor sensitivity for the diagnosis of pathologies of the long head of the biceps: a systematic review and meta-analysis

PURPOSE

To systematically review and meta-analyse the literature to determine which three-dimensional (3D) imaging modality provides the best diagnostic accuracy to detect pathologies of the long head of the biceps tendon (LHBT).

MATERIALS AND METHODS

A search was performed on PubMed, Embase^®, and Cochrane. Studies that compared the diagnostic accuracy of 3D imaging modalities versus arthroscopy for the assessment of LHBT pathologies were included. Studies assessing superior labral anterior posterior (SLAP) lesions were excluded.

RESULTS

Fifteen studies were included; nine were eligible for meta-analysis. Six studies on instability indicated a sensitivity of 0.68 (CI 0.46-0.84) and specificity of 0.76 (CI 0.68-0.82). Four studies on full-thickness tears indicated a sensitivity of 0.56 (CI 0.28-0.81) and specificity of 0.97 (CI 0.93-0.99). Four studies on partial-thickness tears indicated a sensitivity of 0.52 (CI 0.20-0.82) and specificity of 0.64 (CI 0.25-0.91). Two studies on any tear indicated a sensitivity of 0.58 (CI 0.28-0.83) and specificity of 0.99 (CI 0.93-1.00). Only one study on other pathologies indicated a sensitivity of 0.61 and specificity of 0.84.

CONCLUSION

To diagnose LHBT pathologies, 3D imaging modalities overall have low-to-moderate sensitivity, but high-to-excellent specificity. The consistency in reported sensitivity is generally poor, while the consistency and reported specificity is good for the detection of instability, full-thickness tears and any tear, but poor for the detection of partial-thickness tears. 3D imaging may be adequate to rule out LHBT pathologies, but are not sufficiently reliable to confirm the presence of such pathologies.

LEVEL OF EVIDENCE

III.

Arthroscopic Modified Double-Row Biceps Tenodesis versus Labral Repair for the Treatment of Isolated Type II SLAP Lesions in Non-Overhead Athletes

Objective

To evaluate the postoperative efficacy and the clinical outcomes of arthroscopic modified double‐row biceps tenodesis versus labral repair.

Methods

A retrospective study was conducted in 56 patients with isolated type II superior labrum anterior and posterior (SLAP) lesions from March 2015 to November 2018. Thirty patients (male:female = 17:13) were treated with labral repair, and 26 patients (male:female = 15:11) were treated with modified double‐row biceps tenodesis. The average age of the labral repair group and the modified double‐row biceps tenodesis group were 42.8 ± 10.6 and 40.9 ± 10.2 years, respectively. Pre‐ and postoperative assessments with the visual analog scale (VAS), University of California Los Angeles (UCLA), and American Shoulder and Elbow Surgeons (ASES) scores were compared between the two treatment groups. Additional outcome measures included patient satisfaction, the time to return to previous activities, workers' compensation status, and postoperative complications.

Results

At a 2‐year follow‐up, the tenodesis group showed significant differences in postoperative VAS (1.5 to 1.8, respectively; p = 0.008), patient satisfaction (92.3% vs. 46.7%, p < 0.001), and recovery time to return to their previous activities (6.8 ± 1.8 vs. 8.1 ± 1.5, p = 0.007) compared to the labral repair group; however, there was no significant difference in postoperative ASES and UCLA scores between the two groups. Additionally, one patient in the tenodesis group developed persistent postoperative stiffness, which was resolved by conservative treatment. In the labral repair group, two patients presented with persistent postoperative night pain, three developed persistent postoperative stiffness, and two required a subsequent capsular release.

Conclusions

Compared with the labral repair group, the arthroscopic modified double‐row biceps tenodesis showed more encouraging postoperative pain reduction, earlier recovery to previous activities, and higher patient satisfaction.

No Difference in Clinical Outcomes for Arthroscopic Suprapectoral Versus Open Subpectoral Biceps Tenodesis at Midterm Follow-up: A Randomized Prospective Analysis

BACKGROUND

We have previously reported the 1-year outcomes of arthroscopic suprapectoral biceps tenodesis (ASPBT) versus open subpectoral biceps tenodesis (OSPBT) for the management of long head of the biceps tendon (LHBT) pathology. While patients had similar 1-year biceps muscle strength and pain, longer-term functional outcomes are unknown.

PURPOSE

To directly compare clinical outcomes of ASPBT versus OSPBT with interference screw fixation, distal to the bony bicipital groove, at a minimum of 2 years' follow-up.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A total of 85 patients undergoing biceps tenodesis (BT) for LHBT disease were randomized into the ASPBT or OSPBT group. Both techniques utilized polyether ether ketone inference screws for tenodesis fixation. Patients completed American Shoulder and Elbow Surgeons (ASES), Constant subjective, and Single Assessment Numeric Evaluation (SANE) questionnaires preoperatively and again at 6 months, 12 months, and at the final follow-up at a minimum of 24 months.

RESULTS

A total of 73 patients (37/42 randomized to ASPBT [88%]; 36/42 randomized to OSPBT [86%]) with a mean age of 50.4 ± 10.3 years and a mean body mass index of 29 ± 7.9 were included in clinical outcome analyses. The mean final follow-up was 2.9 years (ASPBT, 3 years; OSPBT, 2.8 years [range 2-5.2 years]). Comparison of demographic characteristics and intraoperative findings showed no significant differences in age, sex, concomitant procedures, and rotator cuff disease. No statistically significant differences in the ASES (P = .25), Constant subjective (P = .52), and SANE scores (P = .61) were found at the final follow-up. Clinical outcomes scores showed no significant improvement from a mean of 12.6 months to the final follow-up at 34.5 months (ASPBT: ASES, P = .43; Constant, P = .25; SANE, P = .45 vs OSPBT: ASES, P = .65; Constant, P = .78; SANE, P = .70). No patients required revision of BT in either group.

CONCLUSION

This study reported a minimum of 2-year follow-up of patients undergoing ASPBT or OSPBT, utilizing the same interference screw technique, for the management of LHBT pathology in the setting of concomitant shoulder procedures. There were no significant differences in patient-reported outcomes and complication rates found at any time point.

REGISTRATION

NCT02192073 (ClinicalTrials.gov identifier).

Arthroscopic Evaluation of the Long Head of the Biceps Tendon: Traditional Versus Allis Clamp Techniques

Using a probe to retract the long head of the biceps tendon (LHBT) into the joint is common practice for visualizing the extra-articular portions during arthroscopy. However, extra-articular lesions may be missed in up to half of cases. Greater excursion of the LHBT may be achieved with an Allis clamp grasper. Our goal was to quantify portions of the extra-articular LHBT that could be visualized during shoulder arthroscopy with the Allis clamp and probe techniques. Shoulder arthroscopy was performed on 8 forequarter cadaveric specimens in the simulated beach chair position, and the most distal extent of the intra-articular LHBT was marked. The tendon was pulled into the joint with both techniques, and the additional exposed tendon portion was marked. An open approach was performed, and the locations of the 3 marks were assessed relative to total tendon length. Mean LHBT total length was 96.25 mm. Diagnostic arthroscopy allowed visualization of a mean of 21.75 mm of the intra-articular tendon (22.6% of the total length). The traditional probe technique provided visualization of 31.13 mm (32.8%). The Allis clamp technique provided visualization of 49.38 mm (52%) and increased visualization of the LHBT by 58.6% (P<.0001). A mean of 46.87 mm (48%) of the LHBT remained unvisualized. The Allis clamp technique maximizes arthroscopic visualization of extra-articular LHBT. The distal 48% eludes evaluation, but can be visualized when combined with an open technique without the need to divide the transverse humeral ligament. The Allis clamp technique facilitates additional identification of LHBT pathology that could otherwise remain hidden during shoulder arthroscopy. Because the LHBT is a major source of pain in the shoulder, this technique may improve outcomes of shoulder arthroscopy and reduce the need for revision because of remnant anterior shoulder pain. [Orthopedics. 2022;45(1):38-42.].

Management of proximal biceps tendon pathology

The long head of the biceps tendon is widely recognized as an important pain generator, especially in anterior shoulder pain and dysfunction with athletes and working individuals. The purpose of this review is to provide a current understanding of the long head of the biceps tendon anatomy and its surrounding structures, function, and relevant clinical information such as evaluation, treatment options, and complications in hopes of helping orthopaedic surgeons counsel their patients. An understanding of the long head of the biceps tendon anatomy and its surrounding structures is helpful to determine normal function as well as pathologic injuries that stem proximally. The biceps-labral complex has been identified and broken down into different regions that can further enhance a physician’s knowledge of common anterior shoulder pain etiologies. Although various physical examination maneuvers exist meant to localize the anterior shoulder pain, the lack of specificity requires orthopaedic surgeons to rely on patient history, advanced imaging, and diagnostic injections in order to determine the patient’s next steps. Nonsurgical treatment options such as anti-inflammatory medications, physical therapy, and ultrasound-guided corticosteroid injections should be utilized before entertaining surgical treatment options. If surgery is needed, the three options include biceps tenotomy, biceps tenodesis, or superior labrum anterior to posterior repair. Specifically for biceps tenodesis, recent studies have analyzed open vs arthroscopic techniques, the ideal location of tenodesis with intra-articular, suprapectoral, subpectoral, extra-articular top of groove, and extra-articular bottom of groove approaches, and the best method of fixation using interference screws, suture anchors, or cortical buttons. Orthopaedic surgeons should be aware of the complications of each procedure and respond accordingly for each patient. Once treated, patients often have good to excellent clinical outcomes and low rates of complications.

Mini-Open Subpectoral Biceps Tenodesis Using a Suture Anchor with Bone-Bridge Backup

Pathology of the long head of the biceps tendon is a known cause of anterior shoulder pain. Current surgical management options include tenotomy and tenodesis. Tenodesis can be performed arthroscopically or as an open procedure. Arthroscopic tenodesis typically uses a suprapectoral attachment, which may fail to address tendon pathology in the bicipital groove. Open tenodesis carries iatrogenic risk to neurovascular structures and a fracture risk while drilling, as well as the morbidity of an open procedure. This technique paper describes a mini-open subpectoral approach using a suture anchor and bone bridge backup for dual fixation. Use of a suture anchor instead of an interference screw reduces drill hole diameter reducing the risk of iatrogenic humeral fracture. Dual fixation provides a robust repair which may be of use for athletic patients desiring an accelerated recovery.

Radiographic evaluation of the bicipital groove morphology does not predict intraarticular changes in the long head of biceps tendon

INTRODUCTION AND OBJECTIVES

This study aimed to examine the clinical utility of the radiographic evaluation of the bicipital groove in predicting long head of biceps tendon (LHBT) pathology.

MATERIAL AND METHODS

A prospective study was conducted, and sixty consecutive patients proposed to shoulder arthroscopic surgery were selected. Before surgery, a radiographic evaluation was performed with a supine and a Fisk radiograph. Most supine radiographs (>75%) were non-interpretable and were excluded from the study. As some Fisk radiographs (26.7%) were also non-interpretable, that left 44 interpretable radiographs in the study. These were measured for medial opening angle, total opening angle, width and depth of the bicipital groove. The radiographic measurements and the presence of LHBT pathology, as assessed at arthroscopy, were correlated.

RESULTS

Radiographic evaluation of the bicipital groove showed a mean medial opening angle of 53±15o (23 - 90), a mean total opening angle of 80±26o (30 - 135), a mean width of 10.3±2.5mm (6 - 19) and a mean depth of 4.1±1.5mm (1 - 8). Men had higher medial opening angle (60 vs 50o, p=0.044) and wider grooves (11.9 vs 9.7mm, p=0.019). Twenty-five patients (56.8%) were found to have an abnormal LHBT. No correlation was found between the radiographic measurements and LHBT pathology. Only age was correlated with a LHBT lesion (61.8 vs 46.3 years, p <0.001).

CONCLUSIONS

Our results show that there is no correlation between radiographic morphologic evaluation of the bicipital groove and LHBT pathology.

[Injuries of the biceps-labrum complex : Principles, pathologies and treatment concepts]

BACKGROUND

The biceps-labrum complex is prone to acute lesions and degenerative changes due to its anatomical structure and the high load it has to endure. Pathological changes of these structures are common pain generators and can significantly impair shoulder function. Anatomically, the biceps-labrum complex can be divided into three zones: inside, junction and bicipital tunnel.

DIAGNOSTIC PROCEDURE

Despite the focused physical examination and advancements in imaging techniques, the exact localization of pathologies remains challenging. Arthroscopy can be used to accurately diagnose inside and junctional pathologies but extra-articular changes in the region of the bicipital tunnel can only be partially visualized.

TREATMENT

In cases of unsuccessful conservative treatment and correct indications, a high level of patient satisfaction can be surgically achieved. In young patients an anatomical reconstruction of inside lesions or tenodesis of the long head of the biceps tendon is performed; however, even tenotomy is a valuable option and can achieve equally satisfactory results. Unaddressed pathological changes of the bicipital tunnel can lead to persistence of pain. In clinical procedures performing tenodesis, both the different techniques and the implants used have been found to show similar results. This article describes the anatomical principles, pathological changes, the focused clinical instrumental diagnostics and discusses the different treatment philosophies as well as the outcome according to the recent literature.

Subpectoral Biceps Tenodesis of the Shoulder: Indications and Technique Options

Subpectoral biceps tenodesis of the shoulder may be a useful tool that can address a wide range of disorders in the setting of pathology of the long head of the biceps tendon. Primary indications include (1) zone 2 or zone 3 tendon pathology and (2) failed previous proximal tendon tenodesis. Secondary indications include (1) an overhead athlete or thrower, (2) chronic tendinopathy, and (3) surgeon preference. A subpectoral technique allows tendon fixation directly posterior (deep) to the pectoralis tendon high in the bicipital fossa or in the mid fossa or fixation low in the fossa inferior to the pectoralis tendon (infrapectoral). Fixation technique options include an onlay suture anchor, onlay unicortical button, inlay bicortical button, or inlay interference screw. Potential surgical complications include humeral fracture, loss of fixation, tendon pullout or rupture, and neurovascular injury. Regardless of the specific location or technique used, subpectoral tenodesis is a valuable tool for the treatment of proximal biceps tendon pathology.

Evidence-Based Physical Examination for the Diagnosis of Subscapularis Tears: A Systematic Review

CONTEXT

There is a renewed interest in diagnosing and treating subscapularis tears, but there is a paucity of clinical guidance to optimize diagnostic decision-making.

OBJECTIVE

To perform a literature review to evaluate advanced maneuvers and special tests in the diagnosis of subscapularis tears and create a diagnostic algorithm for subscapularis pathology.

DATA SOURCES

PubMed, MEDLINE, Ovid, and Cochrane Reviews databases.

STUDY SELECTION

Inclusion criteria consisted of level 1 and 2 studies published in peer-reviewed scientific journals that focused on physical examination.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 2.

DATA EXTRACTION

Individual test characteristics (bear hug, belly press, lift-off, Napoleon, and internal rotation lag sign) were combined in series and in parallel to maximize clinical sensitivity and specificity for any special test evaluated in at least 2 studies. A secondary analysis utilized subjective pretest probabilities to create a clinical decision tree algorithm and provide posttest probabilities.

RESULTS

A total of 3174 studies were identified, and 5 studies met inclusion criteria. The special test combination of the bear hug and belly press demonstrated the highest positive likelihood ratio (18.29). Overall, 3 special test combinations in series demonstrated a significant impact on posttest probabilities. With parallel testing, the combination of bear hug and belly press had the highest sensitivity (84%) and lowest calculated negative likelihood ratio (0.21).

CONCLUSION

The combined application of the bear hug and belly press physical examination maneuvers is an optimal combination for evaluating subscapularis pathology. Positive findings using this test combination in series with a likely pretest probability yield a 96% posttest probability; whereas, negative findings tested in parallel with an unlikely pretest probability yield a 12% posttest probability.

Arthroscopic supraglenoid origin-preserving biceps tenodesis: a reliable, simple, and cost-conscious technique

BACKGROUND

The purpose of this study was to assess the midterm clinical and ultrasonographic outcomes of a new all arthroscopic supraglenoid origin-preserving tenodesis technique of the long head of the biceps (LHB) brachii tendon in the setting of small to medium-sized rotator cuff repairs.

MATERIALS AND METHODS

Thirty patients (33 shoulders) meeting inclusion criteria were identified who underwent LHB tenodesis with this technique in the setting of small to medium-sized rotator cuff repair at a mean age at surgery of 65.6 years between 2015 and 2017. Rotator cuff tears were repaired using the Southern California Orthopedic Institute (SCOI) row technique. The biceps tenodesis was incorporated into the anterior anchor of the rotator cuff repair after bony groove preparation, including débridement and bone vent placement. Frayed edges of the biceps tendon were gently débrided, but the intra-articular glenoid attachment was left intact. Patients were assessed at follow-up by clinical and ultrasonographic examination, as well as a satisfaction questionnaire, the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score and visual analog scale (VAS) score.

RESULTS

Mean follow-up was 32.9 months for the 27 patients (30 shoulders), resulting in a 91% follow-up. Average ASES score was 94.4. Average patient-reported satisfaction with shoulder function was 9.4 of 10 and with biceps contour was 9.9 of 10. Average VAS score was 0.6 of 10, and 73% of patients reported a VAS score of 0. Ultrasonography demonstrated an intact biceps tendon in 27 of 28 shoulders and an intact supraspinatus tendon in all 28 shoulders. Mean range of motion was 170° in forward flexion, 169° in abduction, 49° in external rotation, and to thoracic vertebrae 12 in internal rotation. Mean muscle grading during Jobe test was 4.8 of 5. There were no intraoperative complications. No patients required revision surgery.

CONCLUSIONS

In situ arthroscopic biceps tenodesis with maintenance of the glenoid attachment incorporated into rotator cuff repair yields a high rate of healing and consistently excellent functional and cosmetic outcomes as well as patient satisfaction while saving surgical time and cost.

Supraspinatus Muscle Tendon Lesion and Its Relationship with Long Head of the Biceps Lesion

Objective  To identify the clinical, radiological, and arthroscopic correlation of long head of the biceps tendon injuries and their influence on pain when associated with rotator cuff injuries. Methods  Between April and December 2013, 50 patients were evaluated, including 38 (76%) women and 12 (24%) men, with a mean age of 65.1 years old. The patients were operated by the Shoulder and Elbow Group, Discipline of Sports Medicine, Orthopedics and Traumatology Department, Universidade Federal de São Paulo. The subjects underwent repair of the rotator cuff lesion with clinical, radiological and/or arthroscopic evidence of involvement of the long head of the biceps tendon. Results  An association between pain at palpation of the intertubercular groove of the humerus and high-grade partial lesions (partial rupture of the tendon affecting more than 50% of its structure) was observed at the arthroscopy ( p  = 0.003). There was also an association between the high-grade lesion of the long head of the biceps and injury to the supraspinatus muscle tendon ( p  < 0.05). For each centimeter of the supraspinatus muscle tendon injury, the patient presented a 1.7 higher probability of having a high-grade lesion at the long head of the biceps. Conclusion  Pain at the anterior shoulder region during palpation of the intertubercular groove of the humerus may be related to high-grade lesions to the long head of the biceps. Rotator cuff injury and its size are risk factors for high-grade injuries to the long head of the biceps tendon.

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.

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.

Small-incision open distal subpectoral vs. arthroscopic proximal biceps tenodesis for biceps long head tendon lesions with repair of rotator cuff tears

The curative effect of small-incision open distal subpectoral vs. arthroscopic proximal biceps tenodesis for lesions in the long head of the biceps tendon (LHBT) combined with rotator cuff repairs (RCR) has remained controversial. The aim of the present study was to compare the two surgical methods. A total of 71 patients who received surgical treatment for LHBT lesions accompanied by RC tears were analyzed. Following arthroscopic RCR and tendectomy of the affected LHBT, 35 patients underwent small-incision open distal subpectoral tenodesis through a small incision (the subpectoral group), while the remaining 36 patients received arthroscopic proximal tenodesis (the arthroscopic group). The surgery time and intra-operative blood loss were compared between the two groups. In addition, the clinical outcomes were evaluated using scoring systems for the functional assessment of the shoulder joint. The subpectoral group had a shorter surgery time and less intra-operative blood loss than the arthroscopic group (P<0.05). The functional scores of the two groups significantly improved as time passed (P<0.05). The subpectoral group was significantly superior to the arthroscopic group with regard to the American Shoulder and Elbow Surgeons score at 2 weeks post-operatively and visual analog scale score at 2 weeks and 3 months post-operatively (P<0.05). Small-incision open distal subpectoral and arthroscopic proximal tenodesis were demonstrated to effectively improve the function of the shoulder joint and relieve pain caused by LHBT lesions accompanied by RCR. However, small-incision open distal subpectoral tenodesis had the additional advantage of shorter surgery time, less intra-operative bleeding and encouraging early results compared to arthroscopic proximal tenodesis. The study was registered as a clinical trial in the Chinese Trial Registry (no. ChiCTR1800015643).

Diagnostic accuracy of clinical tests directed to the long head of biceps tendon in a surgical population: a combination of old and new tests

BACKGROUND

Our objective was to examine the clinical utility of old and new clinical tests directed to the long head of the biceps tendon (LHBT) and to quantify the importance of proper test interpretation.

METHODS

A consecutive 65 patients scheduled to undergo arthroscopic surgery were selected. Before surgery, 5 clinical tests were performed: Speed, Yergason, upper cut, biceps resisted flexion (BRF), and modified BRF (mBRF) using a dumbbell. Pain in an area other than the bicipital groove was noted. The presence of LHBT disease was assessed at arthroscopy, and the clinical utility of the tests was calculated.

RESULTS

The upper cut test was the most sensitive test and the one with the lowest negative likelihood ratio (0.90 and 0.26, respectively); the Yergason test was the most specific and the one with the highest positive likelihood ratio (0.83 and 2.20, respectively). BRF strength did not correlate with an LHBT lesion. The mBRF test has a sensitivity of 0.34 and a specificity of 0.75. Higher age predicted an increased risk of an LHBT lesion (1.2 times). Different interpretations of the tests can result in a difference of up to 29 percentage points in performance (ie, sensitivity).

CONCLUSION

Our results suggest that the upper cut test should be used as a screening test and that after a positive result, the Speed and the Yergason tests should be used as confirmatory tests.

Diagnostic accuracy of MRI for detection of tears and instability of proximal long head of biceps tendon: an evaluation of 100 shoulders compared with arthroscopy

OBJECTIVE

To evaluate the diagnostic accuracy of magnetic resonance imaging (MRI) for detection of instability and tears of the proximal long head of biceps tendon (LHBT). To assess intraobserver and interobserver agreement.

MATERIALS AND METHODS

We performed a retrospective analysis of prospectively collected data of 100 consecutive shoulders who underwent non-contrast 1.5-T MRI prior to arthroscopic surgery due to rotator cuff injury. Images were independently analyzed by two musculoskeletal radiologists. LHBT was evaluated for presence of tearing (intact, longitudinal split, partial-thickness, or full-thickness) and position (normal, subluxated, and dislocated). Anterosuperior rotator cuff tears were also assessed. The reference standard was arthroscopic surgery. The ramp test was performed in order to evaluate LHBT stability. Diagnostic performance measures were determined and Kappa coefficients assessed agreement.

RESULTS

Concerning the detection of overall tears, sensitivity ranged from 71 to 73% and specificity was 73%. The specificity for full-thickness tears ranged from 75 to 96%. Overall displacement showed sensitivity ranging from 51 to 58% and specificity ranging from 70 to 86%. The specificity of overall displacement combined with anterosuperior rotator cuff tears ranged from 73 to 91%. Interobserver Kappa values were between 0.59 and 0.69. Intraobserver Kappa values were between 0.74 and 0.82.

CONCLUSIONS

MRI has moderate accuracy and good agreement for detection of LHBT tears and instability. There is a tendency for increased specificity for full-thickness tears and for instability in the coexistence of anterosuperior rotator cuff tears.

Clinical Outcomes After Biceps Tenodesis or Tenotomy Using Subpectoral Pain to Guide Management in Patients With Rotator Cuff Tears

PURPOSE

To assess whether preoperative subpectoral tenderness in patients with rotator cuff tears was associated with arthroscopic findings of tendinopathy of the long head of the biceps, as well as whether they had resolution of their subpectoral tenderness postoperatively after tenodesis or tenotomy.

METHODS

Patients presenting between 2011 and 2016 undergoing arthroscopic rotator cuff repair were evaluated preoperatively with the subpectoral biceps test (SBT). This test is performed with the arm adducted and internally rotated to allow palpation of the biceps as it courses under the pectoralis major tendon. Preoperative SBT findings determined operative management with either tenodesis or tenotomy during rotator cuff repair. Patients were followed up postoperatively to assess resolution of subpectoral tenderness with a repeated SBT. Preoperative and postoperative Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Surgeons, and Constant-Murley scores were recorded in all patients.

RESULTS

A total of 128 patients were enrolled in the study, with a mean age of 58 years (range, 33-82 years). Patients with a positive preoperative SBT (n = 68) had significantly lower SANE and Constant-Murley scores preoperatively (P < .01) than patients with a negative SBT (n = 60). All patients with a positive preoperative SBT underwent either tenodesis or tenotomy, with 94% of patients (n = 64) having resolution of subpectoral pain and tenderness at final follow-up. Intraoperatively, 93% of patients with a positive SBT showed gross pathologic changes in the tendon (fraying, erythema, tears, or subluxation) compared with only 65% of patients with negative preoperative examination findings (P < .01). American Shoulder and Elbow Surgeons, Constant-Murley, and SANE scores were significantly increased postoperatively in all patients (P = .02).

CONCLUSIONS

In this group of patients with rotator cuff tears surgically treated with concomitant biceps tenodesis or tenotomy, 94% had resolution of their subpectoral tenderness. A positive SBT was associated with gross pathologic changes of the biceps in 93% of patients.

LEVEL OF EVIDENCE

Level III, prospective comparative study.

Editorial Commentary: Biceps Tendon Tenderness… Is It Enough to Guide Surgical Management?

Pathology of the long head of the biceps tendon is often encountered concurrently with rotator cuff tears. Although both preoperative and intraoperative evaluations may play a role in the decision-making process of when and how to treat the biceps, it can still be a conundrum. The more straightforward tests and reliable evaluation methods we have in our repertoire, the more likely the appropriate treatment choice to address the pathology will be made. The subpectoral biceps test is a helpful examination maneuver as part of the preoperative biceps evaluation.

Injuries of the Biceps and Superior Labral Complex in Overhead Athletes

PURPOSE OF REVIEW

To summarize the current anatomy, biomechanics, presentation, treatment, and outcomes of injuries to the biceps and superior labral complex in overhead athletes.

RECENT FINDINGS

The biceps and superior labral complex is composed of anatomically distinct zones. The inability to accurately diagnose biceps lesions contributes to continued morbidity especially as arthroscopy and advanced imaging fail to fully evaluate the entire course of the biceps tendon. Superior labrum anterior and posterior (SLAP) repair, long head of biceps tenodesis, and tenotomy are the most common operative techniques for surgical treatment of biceps-labral complex (BLC) pathology. Labral repair in overhead athletes has resulted in mixed outcomes for athletes and is best indicated for patients under age 40 years old. Injuries to the BLC are potentially challenging injuries to diagnose and treat, particularly in the overhead athlete. SLAP repair remains the treatment of choice for high-level overhead athletes and patients younger than 40 years of age, while biceps tenodesis and tenotomy are preferred for older patients.

Editorial Commentary: Silly Biceps, Tenodesis Is for Kids!

There is now a strong consensus that the best surgical treatment of a SLAP lesion is often something different from a primary direct repair, especially in older patients in whom postoperative stiffness and persistent pain have led most of us to perform a biceps tenodesis instead. However, treatment of younger patients and especially the overhead athlete group is more problematic and thus controversial. This study demonstrates that biceps tenodesis in these patients can be more successful and have a higher return to sport than SLAP repair alone. There may also be a role for biceps tenodesis AND a SLAP repair but the numbers presented in this paper preclude an analysis of exactly who that group is. When it comes to the treatment of patients with SLAP lesions for whom a very well executed rehabilitation program has failed, understanding the symptoms and demographics of your patients is critical to surgical decision making. The pendulum may swing toward tenodesis, but beware: The correct answer is usually near the center of the arc!

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.

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.

Editorial Commentary: Thank You, Thank You, Thank You… for Demonstrating Histologic Evidence of Shoulder Bicipital Tunnel Disease in the Absence of Magnetic Resonance Imaging Findings

Bicipital tunnel disease is often unvisualized during standard diagnostic arthroscopy. Histolopathologic evidence of disease may be present even in the absence of magnetic resonance imaging findings. Surgical decision making is multifactorial.

Radiologic and Histologic Evaluation of Proximal Bicep Pathology in Patients With Chronic Biceps Tendinopathy Undergoing Open Subpectoral Biceps Tenodesis

PURPOSE

To correlate preoperative magnetic resonance imaging (MRI) and intraoperative anatomic findings within the proximal long head biceps tendon to histologic evaluation of 3 separate zones of the tendon in patients with chronic biceps tendinopathy.

METHODS

Sixteen patients with chronic biceps tendinopathy were treated with open subpectoral biceps tenodesis. Preoperative MRI tendon grading was as follows: normal tendon, increased signal, tendon splitting, incomplete/complete tear. The removed portion of the biceps tendon was split into 3 segments: zone 1, 0-3.5 cm from the labral insertion; zone 2, 3.5-6.5 cm; and zone 3, 6.5-9 cm, and was histologically evaluated using the Bonar score. Tenosynovium adjacent to the tendon was assessed histologically using the Osteoarthritis Research Society International score. CD31, CD3, and CD79a immunohistochemistries were conducted to determine vascularization, T-cell infiltrates, and B-cell infiltrates, respectively. Analysis of variance and Pearson correlations were performed for statistical analysis.

RESULTS

Preoperative MRI showed no significant differences in tendon appearance between zones 1-3. Intraoperative findings included nonspecific degenerative SLAP tears or mild/moderate biceps tenosynovitis in all cases. Significantly (P < .001) higher Bonar scores were noted for tendon in zones 1 (7.9 ± 1.8) and 2 (7.3 ± 1.5) compared with zone 3 (5.0 ± 1.1). Cell morphology scores in zone 1 (1.9 ± 0.4) and zone 2 (1.5 ± 0.6) were significantly higher than that in zone 3 (0.8 ± 0.3) (P < .05). Inflammatory tenosynovium showed weak correlation with tendon changes in zone 1 (r = 0.08), zone 2 (r = 0.03), or zone 3 (r = 0.1).

CONCLUSIONS

In patients with chronic long head biceps tendinopathy who underwent open subpectoral tenodesis, MRI and intraoperative assessment did not show significant structural abnormalities within the tendon despite significant histopathologic changes. Severity of tendon histopathology was more pronounced in the proximal and mid-portions of the tendon.

CLINICAL RELEVANCE

Proximal versus distal biceps tenodesis is a subject of frequent debate. This study contributes to the ongoing evaluation of the characteristics of the proximal biceps in this type of pathologic condition.

Diagnosis and Treatment of Injuries to the Biceps and Superior Labral Complex in Overhead Athletes

PURPOSE OF REVIEW

This review discusses the diagnostic and treatment challenges presented by injuries to the biceps and superior labral complex.

RECENT FINDINGS

A focused patient history, numerous physical examination maneuvers, and appropriate advanced imaging studies must be utilized to reach an accurate diagnosis. Nonoperative management, even in overhead athletes, has demonstrated relatively good outcomes, while operative outcomes have yielded mixed results. The surgeon must take into account a number of variables when choosing the appropriate surgical procedure: labral repair versus biceps tenodesis. Rehabilitation, either as nonoperative management or as a postoperative protocol, should focus on restoring glenohumeral and scapulothoracic strength, endurance, and full, pain-free range of motion, while correcting any deficiencies in balance or rhythm throughout the overhead motion. Despite the operative treatment challenges that SLAP tears present, with new techniques and proper patient selection, overhead athletes with injuries to the biceps and superior labrum complex can return to sport at a high level.

Management of Biceps Tendon Pathology: From the Glenoid to the Radial Tuberosity

Management of proximal and distal biceps tendon pathology is evolving. The long head of the biceps tendon, if inflamed, may be a pain-producing structure. In appropriately indicated patients, a symptomatic long head of the biceps tendon can be surgically managed via tenotomy, tenodesis, and/or superior labrum anterior to posterior repair. In some patients, primary superior labrum anterior to posterior pathology can be managed via biceps tenodesis. Determining which procedure is most appropriate and which technique and implant are preferred for a given patient with biceps tendon pathology is controversial. Less debate exists with regard to the timing of distal biceps tendon repair; however, considerable controversy exists with regard to selection of an appropriate surgical technique and implant. In addition, the treatment of patients with a chronic and/or retracted distal biceps tendon tear and patients in whom distal biceps tendon repair fails is extremely challenging. Orthopaedic surgeons should understand the anatomy of, nonsurgical and surgical treatment options for, and outcomes of patients with proximal or distal biceps tendon pathology.

Long Head of Biceps Tendon Management: a Survey of the American Shoulder and Elbow Surgeons

BACKGROUND

Management of symptomatic long head of biceps tendon (LHBT) pathology remains a source of debate.

QUESTIONS/PURPOSES

The purpose of this study was to identify consensus trends for the treatment of LHBT pathology among specialists.

METHODS

A survey was distributed to members of the American Shoulder and Elbow Society (ASES), consisting of three sections-demographics, case scenarios, and general LHBT pathology management. Cases presented common clinical scenarios, and surgeons reported their management preferences. Consensus responses were defined as > 50% of participants giving a single response.

RESULTS

One hundred and forty-two of 417 (34%) surgeons completed surveys. Forty-seven percent of questions reached a consensus answer. Biceps tenodesis was the overwhelmingly preferred technique in cases demonstrating LHBT pathology, as compared to tenotomy. No consensus, however, was reached regarding a specific surgical technique for biceps tenodesis. The two most popular techniques were arthroscopic tenodesis to bone and open subpectoral biceps tenodesis. Fellowship-trained arthroscopic surgeons and surgeons with a largely arthroscopic practice were more likely to perform tenodesis arthroscopically.

CONCLUSION

ASES members favored biceps tenodesis over tenotomy for surgical management of LHBT pathology, without consensus regarding a specific surgical technique.

Physical examination tests and imaging studies based on arthroscopic assessment of the long head of biceps tendon are invalid

PURPOSE

The aim of this study was to evaluate whether glenohumeral arthroscopy is an appropriate gold standard for the diagnosis of long head of biceps (LHB) tendon pathology. The objectives were to evaluate whether the length of tendon that can be seen at arthroscopy allows visualisation of areas of predilection of pathology and also to determine the rates of missed diagnoses at arthroscopy when compared to an open approach.

METHODS

A systematic review of cadaveric and clinical studies was performed. The search strategy was applied to MEDLINE, PubMed and Google Scholar databases. All relevant articles were included. Critical appraisal of clinical studies was performed using a validated quality assessment scale.

RESULTS

Five articles were identified for inclusion in the review. This included both clinical and cadaveric studies. The overall population comprised 18 cadaveric specimens and 575 patients. Out of the five included studies, three reported the length of LHB tendon visualised during arthroscopy and four reported the rate of missed LHB diagnosis. Cadaveric studies showed that the use of a hook probe allowed arthroscopic visualisation of between 34 and 48 % of the overall length of the LHB. In the clinical series, the rate of missed diagnoses at arthroscopy when compared to open exploration ranged between 33 and 49 %.

CONCLUSIONS

Arthroscopy allows visualisation of only a small part of the extra-articular LHB tendon. This leads to a high rate of missed pathology in the distal part of the tendon. Published figures for sensitivities and specificities of common physical examination and imaging tests for LHB pathology that are based on arthroscopy as the gold standard are therefore invalid. In clinical practice, it is important to note that a "negative" arthroscopic assessment does not exclude a lesion of the LHB tendon as this technique does not allow visualisation of common sites of distal pathology.

LEVEL OF EVIDENCE

IV.

A practical, evidence-based, comprehensive (PEC) physical examination for diagnosing pathology of the long head of the biceps

BACKGROUND

Clinical examination of the shoulder joint has gained attention as clinicians aim to use an evidence-based examination of the biceps tendon, with the desire for a proper diagnosis while minimizing costly imaging procedures. The purpose of this study is to create a decision tree analysis that enables the development of a clinical algorithm for diagnosing long head of biceps (LHB) pathology.

METHODS

A literature review of Level I and II diagnostic studies was conducted to extract characteristics of clinical tests for LHB pathology through a systematic review of PubMed, Medline, Ovid, and Cochrane Review databases. Tests were combined in series and parallel to determine sensitivities and specificities, and positive and negative likelihood ratios were determined for each combination using a subjective pretest probability. The "gold standard" for diagnosis in all included studies was arthroscopy or arthrotomy.

RESULTS

The optimal testing modality was use of the uppercut test combined with the tenderness to palpation of the biceps tendon test. This combination achieved a sensitivity of 88.4% when performed in parallel and a specificity of 93.8% when performed in series. These tests used in combination optimize post-test probability accuracy greater than any single individual test.

CONCLUSION

Performing the uppercut test and biceps groove tenderness to palpation test together has the highest sensitivity and specificity of known physical examinations maneuvers to aid in the diagnosis of LHB pathology compared with diagnostic arthroscopy (practical, evidence-based, comprehensive examination). A decision tree analysis aides in the practical, evidence-based, comprehensive examination diagnostic accuracy post-testing based on the ordinal scale pretest probability.

Hypertrophy of the extra-articular tendon of the long head of biceps correlates with the location and size of a rotator cuff tear

Aims

The aim of this study was to assess hypertrophy of the extra-articular tendon of the long head of biceps (LHB) in patients with a rotator cuff tear.

Patients and Methods

The study involved 638 shoulders in 334 patients (175 men, 159 women, mean age 62.6 years; 25 to 81) with unilateral symptomatic rotator cuff tears. The cross-sectional area (CSA) of the LHB tendon in the bicipital groove was measured pre-operatively in both shoulders using ultrasound. There were 154 asymptomatic rotator cuff tears in the contralateral shoulder. Comparisons were made between those with a symptomatic tear, an asymptomatic tear and those with no rotator cuff tear. In the affected shoulders, the CSAs were compared in relation to the location and size of the rotator cuff tear.

Results

The mean CSA was 21.0 mm2 (4 to 71) in those with a symptomatic rotator cuff tear, 19.9 mm2 (4 to 75) in those with an asymptomatic rotator cuff tear and 14.1 mm2 (5 to 43) in those with no rotator cuff tear. The mean CSA in patients with both symptomatic and asymptomatic rotator cuff tears was significantly larger than in those with no rotator cuff tear (p < 0.001). In the affected shoulders, there were significant differences between patients with more than a medium sized posterosuperior cuff tear and those with an antero-superior cuff tear.

Conclusion

Regardless of the symptoms, there was significant hypertrophy of the extra-articular LHB tendon in patients with a rotator cuff tear. The values were significantly related to the size of the tear. Cite this article: Bone Joint J 2017;99-B:806–11.

Risk Factors for Revision Surgery After Superior Labral Anterior-Posterior Repair: A National Perspective

BACKGROUND

Data regarding risk factors for revision surgery after superior labral anterior-posterior (SLAP) repair are limited to institutional series.

PURPOSE

To define risk factors for revision surgery after SLAP repair among patients in a large national database.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

A national insurance database was queried for patients undergoing arthroscopic SLAP repair (Current Procedural Terminology [CPT] code 29807) for the diagnosis of a SLAP tear. Patients without a CPT modifier for laterality were excluded. Revision surgery was defined as (1) subsequent ipsilateral SLAP repair (CPT 29807), (2) ipsilateral arthroscopic debridement for the diagnosis of a SLAP tear (CPT 29822 or 29823, with diagnosis code 840.7), (3) subsequent ipsilateral arthroscopic biceps tenodesis (CPT 29828), (4) subsequent ipsilateral open biceps tenodesis (CPT 23430), and (5) subsequent biceps tenotomy (CPT 23405). Multivariable binomial logistic regression analysis was performed to identify risk factors for revision surgery after SLAP repair, including patient demographics/comorbidities, concomitant diagnoses, and concomitant procedures performed. Odds ratios (ORs), 95% CIs, and P values were calculated. The estimated financial impact of revision surgery was also calculated.

RESULTS

There were 4751 patients who met inclusion and exclusion criteria. Overall, 121 patients (2.5%) required revision surgery after SLAP repair. Regression analysis identified numerous risk factors for revision surgery, including age >40 years (OR, 1.5; 95% CI, 1.2-1.8; P = .045), female sex (OR, 1.5; 95% CI, 1.3-1.8; P = .010), obesity (OR, 1.8; 95% CI, 1.5-2.2; P = .001), smoking (OR, 2.0; 95% CI, 1.6-2.4; P < .0001), and diagnosis of biceps tendinitis (OR, 3.5; 95% CI, 3.0-4.2; P < .0001) or long head of the biceps tearing (OR, 5.1; 95% CI, 4.1-6.3; P < .0001) at or before the time of surgery. Concomitant rotator cuff repair and distal clavicle excision were not significant risk factors for revision surgery. The cost of revision surgery averaged almost $9000.

CONCLUSION

Risk factors for revision surgery after SLAP repair include age >40 years, female sex, obesity, smoking, and diagnosis of biceps tendinitis or long head of the biceps tearing. The diagnosis of biceps tendinitis (OR, 3.5) or long head of the biceps tearing (OR, 5.1) at or before the time of surgery was an especially significant risk factor for revision surgery. The high cost of revision surgery highlights the importance of appropriate indications to avoid the need for subsequent procedures.

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.

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.

Editorial Commentary: A No-Difference Study That May Make a Difference in the Treatment of Disorders of the Shoulder Biceps Brachii Tendon

Biceps tenodesis for disorders of the biceps brachii is frequently performed; nevertheless the optimum procedure, and particularly the level of tenodesis either above the pectoralis major tendon or inferior to the tendon, is yet to be determined. Both have purported advantages. Studies that do not find a difference in outcomes between the 2 groups in the publishing vernacular are sometimes referred to as no-difference investigations and are slightly less likely to be published, known as publication bias. This may be the rare "no-difference" investigation that makes a difference in the treatment of the biceps brachii.