Isolated Biceps Reflection Pulley Tears Treated With Subpectoral Biceps Tenodesis: Minimum 2-Year Outcomes

Biceps Tenodesis in Patients Age 35 Years and Younger Yields Favorable Clinical Outcomes With Variable Rates of Return to Sport and Complications: A Systematic Review

PURPOSE

To systematically evaluate reported clinical outcomes, return-to-sport (RTS) rates, and complications following biceps tenodesis in patients aged 35 years and younger and compare outcomes between overhead and nonoverhead athletes.

METHODS

A literature search was performed by querying Scopus, EMBASE, and PubMed computerized databases from database inception through August 2022 in accordance with the 2020 Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Studies that evaluated clinical outcomes following biceps tenodesis in patients aged 35 years or younger were included. Study quality was assessed via the Methodological Index for Non-Randomized Studies criteria. Clinical outcomes, RTS rates, and complications were aggregated.

RESULTS

Nine studies from 2011 to 2022 comprising 161 patients (mean age, 25 years; range, 19.7-28.9 years) were included. At an average follow-up of 59 months, postoperative American Shoulder and Elbow Surgeons score ranged from 81.6 to 96 and the mean visual analog scale score ranged from 0 to 2.1. Mean overall RTS rate ranged from 35% to 100% for the entire patient cohort 35% to 86% among overhead athletes, and 46% to 100% among nonoverhead athletes. Among the overhead athletes, 24 were baseball pitchers. 17% to 100% able to return to sport at any level. Complications were reported in 0% to 19% of patients. 0 to 18% of patients underwent revision surgery.

CONCLUSIONS

Biceps tenodesis in patients 35 years of age and younger yields a wide variability in reported RTS rates, excellent clinical outcome scores, and low but variable reported rates of complications, reoperations, and failure.

LEVEL OF EVIDENCE

IV; Systematic Review of Level III and IV studies.

SLAP Repair Versus Subpectoral Biceps Tenodesis for Isolated SLAP Type 2 Lesions in Overhead Athletes Younger Than 35 Years: Comparison of Minimum 2-Year Outcomes

Background:

It remains unclear if young overhead athletes with isolated superior labrum anterior-posterior (SLAP) type 2 lesions benefit more from SLAP repair or subpectoral biceps tenodesis.

Purpose:

To evaluate clinical outcomes and return to sport in overhead athletes with symptomatic SLAP type 2 lesions who underwent either biceps tenodesis or SLAP repair.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A retrospective analysis of prospectively collected data was performed in patients who underwent subpectoral biceps tenodesis (n = 14) or SLAP repair (n = 24) for the treatment of isolated type 2 SLAP lesions. All patients were aged <35 years at time of surgery, participated in overhead sports, and were at least 2 years out from surgery. Clinical outcomes were assessed with the American Shoulder and Elbow Surgeons (ASES) score; Single Assessment Numerical Evaluation (SANE) score; Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score; and the 12-Item Short Form (SF-12) physical component score. Return to sport and patient satisfaction were documented. Clinical failures requiring revision surgery and complications were reported.

Results:

Preoperative baseline scores in both the tenodesis and SLAP repair groups were similar. There were no significant differences between the groups on any postoperative outcome measure: For biceps tenodesis versus SLAP repair, the ASES score was 92.7 ± 10.4 versus 89.1 ± 16.7, the SANE score was 86.2 ± 13.7 versus 83.0 ± 24.1, the QuickDASH score was 10.0 ± 12.7 versus 9.0 ± 14.3, and SF-12 was 51.2 ± 7.5 versus 52.8 ± 7.7. No group difference in return-to-sports rate (85% vs 79%; P = .640) was noted. More patients in the tenodesis group (80%) reported modifying their sporting/recreational activity postoperatively because of weakness compared with patients in the SLAP repair group (15%; P = .022). One patient in each group progressed to surgery for persistent postoperative stiffness, and 1 patient in the tenodesis group had a postoperative complication related to the index surgery.

Conclusion:

Both subpectoral biceps tenodesis and SLAP repair provided excellent clinical results for the treatment of isolated SLAP type 2 lesions, with a high rate of return to overhead sports and a low failure rate, in a young and high-demanding patient cohort. More patients reported modifying their sporting/recreational activity because of weakness after subpectoral tenodesis.

Arthroscopic Subcoracoid Decompression, Coracoplasty, and Subscapularis Repair for Subscapularis Tears in the Setting of Subcoracoid Impingement

Subscapularis tears have been found to occur in the setting of subcoracoid impingement and are related to the narrowing of the coracohumeral interval. The advancement of arthroscopic techniques has allowed for improved identification and treatment of this historically overlooked pathology. Challenges of arthroscopic subscapularis treatment include nearby neurovascular structures, tendon retraction, and adhesions, which are further complicated by diminished arthroscopic visualization, resulting from the concomitant subcoracoid impingement. The purpose of this Technical Note is to describe our preferred technique for arthroscopic management of subscapularis tears in the setting of subcoracoid impingement that is simple and reproducible, as well as cost-effective and efficient with limited additional morbidity to that of a standard diagnostic shoulder arthroscopy.

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.

Arthroscopic diagnosis of long head of biceps tendon instability in refractory anterior shoulder pain: A comparison study between pulley tear and non-tear lesions

BACKGROUND

Long head of the biceps tendon (LHBT) instability and biceps reflection pulley (BRP) lesions are common cause of refractory anterior shoulder pain. We described a technique using dynamic arthroscopy to determine associated intraarticular pathologies.

METHODS

Patients with refractory anterior shoulder pain and arthroscopically-diagnosed LHBT instability were enrolled. LHBT instability and the integrity of BRP and concomitant intra-articular lesions were investigated by ramp test. Demographics and arthroscopic findings were compared between patients with and without BRP tear.

RESULTS

Forty patients were enrolled. BRP tear was noted in 25 patients (group A) and superior glenohumeral ligament (SGHL) insufficiency through ramp test in 15 patients (group B). Concomitant intraarticular pathologies were noted in 27 patients, including 19 in group A (76%) and eight in group B (53%), without significant group-wise difference (p = 0.138). The incidence of articular-side subscapularis tear was significantly higher in group A (p = 0.021), and those of the other intraarticular pathologies were similar between groups A and B. Fraying at the articular side of the subscapularis and supraspinatus tendons was frequent in group B, without difference of incidence as compared to group A (p = 0.5 and p = 0.084, respectively).

CONCLUSIONS

LHBT instability was a common disorder in patients with refractory shoulder pain. In those patients, dynamic assessment of BRP lesions and SGHL insufficiency and meticulous survey of associated intra-articular pathologies, including subscapularis tear are necessary for making accurate diagnosis and treatment decision.

Isolated Biceps Tenodesis and Tenotomy: A Systematic Review of Indications and Patient Satisfaction

Biceps tenodesis and tenotomy are increasingly being used as treatment options for shoulder pathology, but patient satisfaction remains largely unstudied. A systematic review of the MEDLINE database was conducted to identify clinical outcome studies on isolated biceps tenodesis or tenotomy that reported patient satisfaction. Within the 15 investigations that were included, the indication for tenotomy was rotator cuff pathology, whereas the indication for tenodesis was biceps pathology or type 2 superior labral tear from anterior to posterior. Patients undergoing tenotomy were 13.6 years older than those undergoing tenodesis (P<.001). Patient satisfaction was high following both procedures, at 85.6% following tenotomy and 92.3% following tenodesis. [Orthopedics. 2021;44(6):333-340.].

[Irreparable rotator cuff tear-reverse shoulder arthroplasty and alternative procedures]

Irreparable rotator cuff tears represent a significant everyday clinical challenge. A high degree of tendon retraction and muscle degeneration means that a direct reconstruction is impossible. Patients often suffer from pain and pseudoparalysis. In older patients this can reliably be resolved by the implantation of a semiconstrained inverse shoulder prosthesis; however, for younger patients joint-preserving techniques should be employed. Furthermore, for frail older patients who may not be suitable for a joint replacement operation, alternative treatment strategies are required. Management options include physiotherapy and pain relieving or reconstructive operations. Minimally invasive arthroscopic treatment approaches can lead to pain relief and slight functional improvements in selected patients; however, to restore the active movement of the joint a partial cuff repair, augmentation with a graft or replacement with muscle transfer is necessary. This article presents the various treatment options and the results reported in the literature. Through this a treatment algorithm is suggested in order to facilitate management decisions.

How can we define clinically important improvement in pain scores after biceps tenodesis?

BACKGROUND

Patient postoperative pain is an important consideration following biceps tenodesis. The visual analog scale (VAS) for pain is one of the most commonly used measures for perioperative pain assessment. Currently, there is limited understanding of clinically significant improvement in VAS pain.

PURPOSE

To define the substantial clinical benefit (SCB), patient acceptable symptomatic state (PASS), and minimal clinically important difference (MCID) for the VAS pain score in patients undergoing open subpectoral (OSPBT) or arthroscopic suprapectoral biceps tenodesis (ASPBT) at 1 year from surgery; and to identify preoperative predictors of achieving each outcome end point.

METHODS

Data from consecutive patients who underwent isolated biceps tenodesis between January 2014 and March 2017 were collected and analyzed. Baseline data and postoperative patient-reported outcome (PRO) scores were recorded at 1 year postoperatively. In order to quantify the clinical significance of outcome achievement for the VAS pain score, the MCID, PASS, and SCB were calculated.

RESULTS

A total of 165 patients were included in the final analysis. The VAS pain score threshold for achieving MCID was defined as a decrease of 12.9 (0-100). PASS was defined as achieving a 2-year postoperative score of 27.4 points (0-100), and SCB was defined as a decrease of 25.1 (0-100) at 1-year follow-up. The rates of achieving MCID, PASS, and SCB were 73.3%, 52.8%, and 45.9%, respectively. Multivariate regression analysis demonstrated that ASPBT (P = .01) and a lower preoperative Constant-Murley score were predictive of achieving the MCID (P = .01). In contrast, a lower preoperative score on the SF-12 Physical Component Summary (P = .01) and a higher score on the preoperative American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (P < .001) were predictive of achieving the SCB and PASS, respectively. Preoperative duration of symptoms >6 months was predictive of a reduced likelihood to achieve PASS.

CONCLUSION

This study identified scores for VAS pain that can be used to define clinically significant outcome after biceps tenodesis. Specifically, a decrease in pain score of 12.9 was a clinically important improvement in VAS pain, whereas a decrease of 25.1 represented the upper threshold of VAS pain improvement. Additionally, there were both modifiable and nonmodifiable factors that predicted achieving clinically significant levels of postoperative pain improvement.

The majority of patients return to athletic activity following biceps tenodesis

PURPOSE

Biceps tenodesis is widely used as a primary treatment for long head of the biceps brachii pathology and superior labral anterior and posterior (SLAP) lesions. However, rates and timing of full return to sports (RTSs)/duty have not been systematically analysed. This systematic review examines the literature to ascertain the rate and timing of return to athletic activity, and the availability of specific criteria for safe return to atheletic activity following the biceps tenodesis.

METHODS

Based on PRISMA guidelines, this systematic review utilised the EMBASE, MEDLINE, and The Cochrane Library Databases. Eligible for inclusion were clinical studies reporting on return to athletic activity following biceps tenodesis. Statistical analysis was performed using SPSS.

RESULTS

This review identified 17 studies including 374 cases meeting the inclusion criteria. The majority of patients were men 260 (69.7%), with an median age of 42.2 years (range 16-88) and a mean follow-up of 37.4 months. The overall rate of RTS was 217/269 (80.7%), with 43/59 (72.9%) returning to the same level. In overhead athletes, the overall rate of return to play was 39/49 (79.6%). Among military personnel, the overall rate of return to duty was 61/74 (82.4%). The average time to RTS was 5.4 (range 3-11) months. 10 (58.8%) Studies reported a recommended time window within which patients were allowed to return to full activity. Specific criteria for return to play were not reported in any of the identified studies.

CONCLUSION

While overall rate of return to athletic activity was reportedly high following biceps tenodesis, one in four patients were not able to resume athletic activity at the same level. At present, there is no objective assessment of when patients can return to full activity reported in the literature.

LEVEL OF EVIDENCE

IV.

Outcomes and Complications After Primary Arthroscopic Suprapectoral Versus Open Subpectoral Biceps Tenodesis for Superior Labral Anterior-Posterior Tears or Biceps Abnormalities: A Systematic Review and Meta-analysis

Background:

Biceps tenodesis is a surgical treatment for both superior labral anterior-posterior (SLAP) tears and long head of the biceps tendon (LHBT) abnormalities. Biceps tenodesis can be performed either above or below the pectoralis major tendon with arthroscopic or open techniques.

Purpose:

To analyze the outcomes and complications comparing primary arthroscopic suprapectoral versus open subpectoral biceps tenodesis for either SLAP tears or LHBT disorders.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A search strategy based on the PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) protocol was used to include 18 articles (471 patients) from a total of 974 articles identified. Overall exclusion criteria included the following: non–English language, non–full text, biceps tenodesis with concomitant rotator cuff repair, review articles, meta-analyses, and case reports. Data were extracted and analyzed according to procedure type and tenodesis location: arthroscopic suprapectoral biceps tenodesis (295 patients) versus open subpectoral bicepts tenodesis (176 patients).

Results:

For arthroscopic suprapectoral biceps tenodesis, the weighted mean American Shoulder and Elbow Surgeons (ASES) score was 90.0 (97 patients) and the weighted mean Constant score was 88.7 (108 patients); for open subpectoral biceps tenodesis, the mean ASES score was 91.1 (199 patients) and mean Constant score was 84.7 (65 patients). Among the 176 patients who underwent arthroscopic biceps tenodesis, there was an overall complication rate of 9.1%. Among the 295 patients who underwent open biceps tenodesis, there was an overall complication rate of 13.5%. Both residual pain (5.7% vs 4.7%, respectively) and Popeye deformity (1.7% vs 1.0%, respectively) rates were similar between the groups. Open subpectoral biceps tenodesis had higher reoperation (3.0% vs 0.0%, respectively), wound complication (1.0% vs 0.0%, respectively), and nerve injury (0.7% vs 0.0%, respectively) rates postoperatively. A meta-analysis of 3 studies demonstrated that both methods had similar ASES scores (P = .36) as well as all-cause complication rates (odds ratio, 0.76 [95% CI, 0.13-4.48]; P = .26).

Conclusion:

Patients undergoing arthroscopic suprapectoral biceps tenodesis for either SLAP tears or LHBT abnormalities had similar outcome scores and complication rates compared with those undergoing open subpectoral biceps tenodesis. Additionally, both residual pain and Popeye deformity rates were similar between the 2 groups.

Subpectoral Biceps Tenodesis: All-Suture Anchor Onlay Technique

Surgical management for biceps pathologies has advanced to provide stronger fixation and to be less invasive. The long head of the biceps tendon has been recognized as a common contributor to anterior shoulder pain and is often associated with other glenohumeral pathologies such as SLAP lesions, rotator cuff tears, and subacromial impingement. Both tenotomy and tenodesis have shown to be effective in ameliorating pain associated with the long head of the biceps tendon. However, decreased muscle function and cosmetic concerns are seen at higher rates after tenotomy compared with tenodesis. One option for the treatment of biceps tendon pathology includes mini-open subpectoral biceps tenodesis. Lower reoperation rates are observed after subpectoral biceps tenodesis than after suprapectoral biceps tenodesis, with thoughts that releasing the tendon from its sheath and the bicipital groove relieves the patient of most associated pain. The purpose of this Technical Note is to describe in detail our preferred operative technique for mini-open subpectoral biceps tenodesis using an onlay technique with all-suture anchor fixation.

Clinical and Imaging Outcomes After Arthroscopic Superior Capsule Reconstruction With Human Dermal Allograft for Irreparable Posterosuperior Rotator Cuff Tears: A Minimum 2-Year Follow-Up

PURPOSE

To report the clinical and structural outcomes for non-pseudoparalytic irreparable posterosuperior rotator cuff tears treated with superior capsule reconstruction (SCR) using dermal allograft (DA).

METHODS

Patients who underwent SCR using DA with a mean thickness of 3 mm for irreparable posterosuperior rotator cuff tears and underwent surgery at least 2 years earlier were included. Outcomes were assessed prospectively by the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation, and Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores; patient satisfaction; and visual analog scale for pain. Structurally, acromiohumeral distances (AHDs) were assessed both preoperatively and postoperatively (standard radiographs). Graft integrity was assessed by magnetic resonance imaging. Clinical failures were reported.

RESULTS

We included 22 patients with a mean age of 56 years (range, 41-65 years) and a mean follow-up period of 2.1 years (range, 2-3 years). The ASES score improved from 54.0 to 83.9 (P < .001); the Single Assessment Numeric Evaluation score improved from 44.9 to 71.4 (P < .001); and Quick Disabilities of the Arm, Shoulder and Hand score (QuickDASH) improved from 37.6 to 16.2 (P = .001). Of the patients, 85% achieved an improvement in the ASES score that exceeded the minimal clinically important difference (11.1 points). The median patient satisfaction rating was 8.5 (range, 1-10). The median preoperative visual analog scale score decreased from 4 to 0 (range, 0-3) postoperatively (P < .001). Complete radiographs of 19 of 22 patients (86%) were obtained at a mean of 5.2 months (range, 1.4-10 months) postoperatively and showed a significant increase in the mean AHD from 7.0 mm preoperatively to 8.3 mm postoperatively (P = .029). Postoperative magnetic resonance imaging scans were obtained in 95% of the patients (21 of 22) at a mean of 2.5 months (range, 0.3-10.2 months) postoperatively and showed graft integrity rates of 100% (21 of 21) on the tuberosity side, 76% (16 of 21) at the midsubstance, and 81% (17 of 21) on the glenoid side. No significant differences in clinical outcome scores (P > 0.930) were found in patients with intact grafts versus those with torn grafts. The number of previous shoulder surgical procedures was a negative predictor of clinical outcome. There was 1 clinical failure.

CONCLUSIONS

SCR using DA for irreparable tears improves outcomes with high satisfaction and high graft integrity at short-term follow-up. Graft integrity, although correlated with an increased AHD, had no correlation with clinical outcomes at final follow-up.

LEVEL OF EVIDENCE

Level IV, case series.

Minimum Five-year Outcomes and Clinical Survivorship for Arthroscopic Transosseous-equivalent Double-row Rotator Cuff Repair

INTRODUCTION

Despite the widespread use of arthroscopic double-row transosseous-equivalent (TOE) rotator cuff repair (RCR) techniques, midterm outcome data are limited. The purpose of this article was to assess midterm clinical outcomes of patients following arthroscopic TOE RCR using either a knotless tape bridge (TB) repair or knotted suture bridge (SB) repair technique. We hypothesized that there would be significant improvements in patient-reported outcomes with TOE RCR that would be durable over time. We also hypothesized that the knotless TB technique would yield equivalent clinical results to the knotted SB technique, but that there would be differences in retear types between the two TOE techniques.

METHODS

Patients included were a minimum of 5 years from an index arthroscopic double-row TOE repair using either a knotless TB or knotted SB technique for one, two, or three tendon full-thickness rotator cuff tears involving the supraspinatus tendon. Preoperative and postoperative American Shoulder and Elbow Surgeons, Short-Form 12 Physical Component Summary, Quick Disabilities of the Arm, Shoulder, and Hand, Single Assessment Numeric Evaluation, and satisfaction scores were collected. Scores were also stratified and compared based on primary and revision repair, tear location, and tear chronicity. Outcomes between techniques were contrasted, and survivorship analysis was conducted, with failure defined as progression to revision surgery.

RESULTS

One-hundred ninety-two shoulders were included with a mean follow-up of 6.6 years (range, 5.0 to 11.0 years). Fifteen shoulders (7.8%) underwent revision cuff repair. All scores improved significantly for TB repair (P < 0.001). For SB repair, all scores improved, but only American Shoulder and Elbow Surgeons and Short-Form 12 Physical Component Summary scores (P < 0.05) demonstrated statistical significance. No statistically significant differences were found between the repair techniques when stratified by primary and revision repairs, tear location, or chronicity. Postoperative clinical survivorship was 96.6% and 93.6% for knotted SB repairs and 96.7% and 93.9% for knotless TB repairs at 2 and 5 years, respectively.

CONCLUSION

TOE RCR results in significant clinical improvement and excellent survivorship at a minimum of 5 years of follow-up, using either knotted SB or knotless TB repair techniques in primary and revision cases and in small and large tears. Equivalent results were obtained with both TOE techniques. Patients undergoing repair with a TOE showed significant improvements in patient-reported outcomes that were durable at a minimum of 5 years postoperatively.

Biomechanical Comparison of Subpectoral Biceps Tenodesis Onlay Techniques

Background:

Subpectoral biceps tenodesis can be performed with cortical fixation using different repair techniques. The goal of this technique is to obtain a strong and stable reduction of biceps tendon in an anatomic position.

Purpose/Hypothesis:

The purpose of this study was to compare (1) displacement during cyclic loading, (2) ultimate load, (3) construct stiffness, and (4) failure mode of the biceps tenodesis fixation methods using onlay techniques with an all-suture anchor versus an intramedullary unicortical button. It was hypothesized that fixation with all-suture anchors using a Krackow stitch would exhibit biomechanical characteristics similar to those exhibited by fixation with unicortical buttons.

Study Design:

Controlled laboratory study.

Methods:

Ten pairs of fresh-frozen cadaveric shoulders (N = 20) were dissected to the humerus, leaving the biceps tendon-muscle unit intact for testing. A standardized subpectoral biceps cortical (onlay) tenodesis was performed using either an all-suture anchor or a unicortical button. The biceps tendon was initially cycled from 5 to 70 N at a frequency of 1.5 Hz. The force on the tendon was then returned to 5 N, and the tendon was pulled until ultimate failure of the construct. Displacement during cyclic loading, ultimate failure load, stiffness, and failure modes were assessed.

Results:

Cyclic loading resulted in a mean displacement of 12.5 ± 2.5 mm for all-suture anchor fixation and 29.2 ± 9.4 mm for unicortical button fixation (P = .005). One all-suture anchor fixation and 2 unicortical button fixations failed during cyclic loading. The mean ultimate failure load was 170.4 ± 68.8 N for the all-suture anchor group and 125.4 ± 44.6 N for the unicortical button group (P = .074), with stiffness 59.3 ± 11.6 N/mm and 48.6 ± 6.8 N/mm (P = .091), respectively. For the unicortical button, failure occurred by suture tearing through tendon in 100% of the specimens. For the all-suture anchor, failure occurred by suture tearing through tendon in 56% and knot failure in 44% of the specimens.

Conclusion:

The all-suture anchor fixation using a Krackow stitch for subpectoral biceps tenodesis provided ultimate load and stiffness similar to unicortical button fixation using a nonlocking whipstitch. The all-suture anchor fixation technique was shown to be superior in terms of displacement during cyclic loading when compared with the unicortical button fixation technique. However, the results of this study help to show that the fixation method used on the humeral side is less implicative of the overall construct strength than stitch location and technique, as the biceps tendon tissue and stitch configuration seem to be the limiting factor in subpectoral onlay tenodesis techniques.

Clinical Relevance:

All-suture anchors have a smaller diameter than traditional suture anchors, can be inserted through curved guides, and preserve humeral bone stock without compromising postoperative imaging. This study supports use of the all-suture anchor fixation technique for subpectoral biceps tenodesis, with high biomechanical fixation strength and low displacement, as an alternative to the subpectoral onlay biceps tenodesis technique.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Biceps Tenodesis Is a Viable Option for Management of Proximal Biceps Injuries in Patients Less Than 25 Years of Age

PURPOSE

To evaluate outcomes after biceps tenodesis performed in patients younger than 25 years, to evaluate reoperations and complications in this population, and to critically appraise return to preinjury level of play for this population.

METHODS

Forty-five consecutive patients younger than 25 years underwent subpectoral biceps tenodesis for biceps tendinopathy or biceps-labral complex injuries including SLAP tears. Biceps tenodesis was performed using an interference screw technique. Patients with a minimum 2-year follow-up were analyzed. Functional outcomes were assessed with the visual analog scale score, American Shoulder and Elbow Surgeons (ASES) score, ASES functional score, Simple Shoulder Test score, and range of motion. Activity level and return to sport were followed postoperatively.

RESULTS

Of the 45 patients younger than 25 years who underwent biceps tenodesis, 36 (80%) were available for follow-up at a minimum of 2 years, with a mean age of 19.8 years and mean follow-up period of 38.6 months. Of these 36 patients, 34 (94%) were athletes, with 20 patients playing at collegiate level. All clinical outcome scores improved, with the ASES score improving from 54.7 to 81.7, the ASES functional score improving from 17.5 to 25.1, and the Simple Shoulder Test score improving from 7.4 to 10.1 (P < .001). At the time of follow-up, 4 patients (11%) had undergone revision surgery for other injuries. Of the 34 athletes, 25 (73%) returned to sports, with 19 returning at the same level and 6 returning at a lower level of play; 77% of overhead athletes returned to sports.

CONCLUSIONS

When indicated, biceps tenodesis offers an alternative to SLAP repair in young patients. Biceps tenodesis in patients younger than 25 years yields satisfactory outcomes, with two-thirds of patients returning to sport and a low revision rate.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Editorial Commentary: Is Arthroscopic In Situ Repair Effective for Long-Term Functional Recovery and Pain Relief in Symptomatic Partial Rotator Cuff Tears?

Currently, although most evidence suggests that surgery is effective in treating symptomatic partial-thickness rotator cuff tears in patients with failure of nonoperative management and with a tear of more than 50% of the tendon thickness, there is little consensus on the best method of repair. Some surgeons would advocate completing the tear and repairing it, whereas others would advocate performing in situ repair. In our opinion, it is important to also consider treating the long head of the biceps tendon, which is frequently a source of pain at the time of or after surgery.

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.

Editorial Commentary: Arthroscopic Subscapularis Repair: Bridging Successful Tendon Healing and Improved Patient Outcomes

Open repair has been regarded as the gold standard for the treatment of subscapularis tendon tears. However, recent studies on newer arthroscopic techniques and published results of arthroscopic repair have shown promising results. As such, there exists a growing interest in understanding the best fixation technique to obtain successful functional and patient-reported clinical outcomes. While the literature shows superior outcomes after double-row repair for posterosuperior rotator cuff tears compared with single-row repair, the evidence is inconclusive for subscapularis tears. We believe that arthroscopic double-row transosseous equivalent repair of full-thickness subscapularis tears leads to superior clinical outcomes with higher healing rates and will become the standard of care in the future.

Editorial Commentary: Treating Hidden Lesions Using Hidden Data: Isolated Lesions of the Shoulder Biceps Pulley

In a study evaluating a rare condition (isolated lesions of the shoulder biceps pulley), retrospective analysis of a comprehensive, prospective surgical database allows authors to determine the results for the surgical management of this uncommon pathology. The creation and use of a comprehensive surgical database can help surgeons evaluate their own data to help improve patient outcomes. The authors present favorable data on the effectiveness of open subpectoral biceps tenodesis to treat isolated biceps reflection pulley lesions. By maintaining a comprehensive surgical database the authors were able to evaluate their results for the surgical management of this uncommon pathology. The creation and maintenance of a surgical database can help monitor and improve patient outcomes in any practice.