Suprapectoral versus subpectoral tenodesis for Long Head Biceps Brachii tendinopathy: A systematic review and meta-analysis

No clinical difference in outcomes between inlay and onlay arthroscopic biceps tenodesis techniques during rotator cuff repair

BACKGROUND

Both inlay and onlay arthroscopic biceps tenodesis (ABT) are common procedures performed during rotator cuff repair. The inlay method involves creating a bone socket in the bicipital groove to secure the long head of the biceps tendon using an interference screw. The onlay method utilizes a suture anchor to secure the long head of the biceps tendon on the surface of the bicipital groove. Little is known on the long-term differences in patient-reported outcomes between these 2 techniques. The primary purpose of this study was to compare patient-reported outcomes of inlay vs. onlay ABT with a minimum follow-up of 2 years. Secondary aims were to evaluate the impact of rotator cuff tear size on outcomes and compare rates of complications between the 2 techniques.

METHODS

A retrospective chart review was performed to identify patients who had an ABT during a full-thickness rotator cuff repair. Any symptom specific to the biceps were noted, including pain and cramping, Popeye deformity, or revision surgery. Complication rates were compared between groups. The visual analog scale pain score, American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation, and Veteran's RAND-12 score (VR-12) scores were compared at 2 years. The impact of rotator cuff tear size was analyzed by categorizing into small/medium or large/massive based on operative reports and arthroscopic images.

RESULTS

There were 165 patients identified (106 in the inlay group and 59 in the onlay group). No revision surgeries were performed secondary to the biceps tendon in either group. Eleven patients (10%) in the inlay group complained of biceps pain or cramping compared to 2 patients (3%) in the onlay group (P = .11). One Popeye deformity was noted in each group (P = .67). No significant differences were found between groups for visual analog scale (P = .41), ASES functional (P = .61), ASES index (P = .91), Single Assessment Numeric Evaluation (P = .09), VR-12 Physical Component Score (P = .77), or VR-12 Mental Component Score (P = .09). Rotator cuff tear size within the groups also did not demonstrate statistical significance.

CONCLUSION

No clinical differences or complications were found at minimum 2-year follow-up between inlay and onlay ABT in patients undergoing rotator cuff repair when controlling for tear size. The clinical relevance suggests either technique is effective and can be based on surgeon preference.

Variations in subpectoral biceps tenodesis locations do not impact clinical outcomes

Background

Biceps tenodesis is a common treatment for pathologies involving the long head of the biceps brachii. Given variations in surgical approach, focus has been placed on the location of the tenodesis to maintain appropriate length-tension relationship. The purpose of this study is to assess for variations in the tunnel placement in subpectoral biceps tenodesis procedures and correlation of tunnel position with patient-reported outcomes.

Methods

This is a retrospective case series of outcomes as a function of tunnel location with open subpectoralis biceps tenodesis. The location of the biceps tenodesis tunnel was measured on postoperative Grashey radiographs. Correlation between the tenodesis tunnel and postoperative American Shoulder and Elbow Surgeons (ASES) score and Visual Analog Scale (VAS) was assessed.

Results

31 patients were included in the study with an average follow-up of 17 months. The overall tunnel position from the superior edge of the greater tuberosity ranged from 4.20 cm to 12.61 cm, with an average of 7.46 cm. Final ASES score and VAS were 84.5 and 1.2, respectively. There was only weak correlation between both ASES score and tunnel position (r = -0.12) and VAS and tunnel position (r = -0.23).

Discussion

Subpectoralis biceps tenodesis continues to be a viable treatment option for biceps and superior labral pathology. There remains no consensus on tenodesis location, and this study found no significant difference between tunnel location and patient-reported outcomes. Therefore, it is likely that a range of tenodesis locations exists in which favorable clinical results are achieved, explaining the numerous recommendations on tunnel placement.

Evaluating clinical outcomes of two biceps tenodesis techniques: Loop 'N' Tack and subpectoral biceps tenodesis

Purpose

Biceps tenodesis is an effective surgical procedure that can address pathologies of the long head of the biceps tendon. The purpose of this study was to evaluate clinical outcomes following two different biceps tenodesis techniques: Loop 'N' Tack biceps tenodesis and subpectoral biceps tenodesis.

Hypothesis

Patients undergoing both the subpectoral biceps tenodesis and Loop 'N' Tack biceps tenodesis will have improvements in patient-reported outcomes.

Methods

Hundred and sixty five consecutive patients who underwent biceps tenodesis were retrospectively identified and contacted by phone to collect visual analog scale pain scores, University of California, Los Angeles shoulder scores, Simple Shoulder Test scores, Single Assessment Numeric Evaluation scores, and American Shoulder and Elbow Surgeons scores. Range of motion, elbow flexion strength, and incidence of bicipital groove pain and Popeye deformity were recorded.

Results

One Hundred and forty five patients were included in the study (55 subpectoral, 90 Loop 'N' Tack). Patients in both groups reported high American Shoulder and Elbow Surgeons, Simple Shoulder Test, University of California, Los Angeles, Single Assessment Numeric Evaluation shoulder function scores, low visual analog scale pain scores, and had a minimal risk of complications when measured one year postoperatively.

Conclusion

Loop 'N' Tack biceps tenodesis and subpectoral biceps tenodesis techniques are reliable and effective procedures that can reduce pain scores and restore shoulder function when patients require surgical intervention.

Biomechanical properties of suprapectoral biceps tenodesis with double-anchor knotless luggage tag sutures vs. subpectoral biceps tenodesis with single-anchor whipstitch suture using all-suture anchors

Background

As the use of all-suture anchors continues to increase, limited biomechanical data on the use of these anchors in various configurations for tenodesis of the long head biceps tendon (LHBT) exists. The aim of this study was to compare the biomechanical properties of a 2-anchor luggage tag suprapectoral biceps tenodesis (Sup-BT) vs. a single-anchor whipstitch subpectoral biceps tenodesis (Sub-BT) using all-suture anchors. The hypothesis was that the Sub-BT will have a higher ultimate load to failure and less creep relative to the Sup-BT construct.

Methods

Eighteen fresh frozen cadaveric humeri were used. The specimens were randomly divided into 2 groups of 9; i) The Sup-BT were performed with 2 1.8 mm knotless all-suture anchors using a luggage-tag fixation configuration, ii) The Sub-BT were performed using a single 1.9 mm all-suture anchor and a whipstitch suture configuration with a tied knot. The humeri were tested on a hydraulic MTS machine where the specimens were preloaded at 5 N for 2 minutes and then cyclically loaded from 5 to 50 N for 1000 cycles at 1 Hz while maximum displacement was recorded with a motion system and markers attached to the bone and bicep tendon. The tendon was then tensioned at a rate of 1 mm/s to obtain the ultimate load to failure. CT scans of the specimens were used to calculate the bone mineral density at the site of the anchor/bone interface and video recordings were captured during load to failure to document all modes of failure.

Results

There was no significant difference in the average load to failure of the Sup-BT and Sub-BT groups (197 N ± 45 N (SD), 164 N ± 68 N (SD) respectively; P = .122) or creep under fatigue between the Sup-BT vs. Sub-BT specimens (3.1 mm, SD = 1.5 vs. 2.2 mm, SD = 0.9; P = .162). The bone mineral density was statistically different between the 2 groups (P < .001); however, there were no observed failures at the anchor/bone interface and no correlation between failure load and bone mineral density.

Conclusion

The ultimate load to failure and creep between a Sup-BT with 2 knotless all-suture anchors using a luggage tag suture configuration was equivalent to a Sub-BT with 1 all-suture anchor using a whipstitched suture configuration and a tied knot. Surgeons can perform either technique confidently knowing that they are biomechanically equivalent in a cadaver model at time zero, and they offer similar strength to other fixation methods cited in the literature.

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.

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.

Onlay Versus Inlay Biceps Tenodesis for Long Head of Biceps Tendinopathy: A Systematic Review and Meta-analysis

INTRODUCTION

Proximal biceps tenodesis is a common surgical treatment of tendinosis of the long head of the biceps tendon. Two of the most common techniques incorporate onlay and inlay fixation methods, which can be done arthroscopically or open and in a variety of anatomic locations. The purpose of this meta-analysis was to compare the clinical outcomes between onlay versus inlay humeral fixation for biceps tenodesis for long head of the biceps tendon pathology.

METHODS

A literature search was conducted using PubMed, EMBASE, and Cochrane Library. Only studies reporting outcomes and complications after onlay and inlay biceps tenodeses were included.

RESULTS

Six studies with a total of 418 patients (252 onlay, 166 inlay) with a mean age of 56.84 years were included. Visual analog pain scale scores, Constant score, and American Shoulder and Elbow Surgeons shoulder score did not differ. "Popeye" deformity was found in 17 patients (7.80%) in the onlay group and in 15 patients (11.28%) in the inlay group (odds ratio, 0.28; P = 0.07). No difference in postoperative cramping or failure rates was found.

CONCLUSION

Both onlay and inlay biceps tenodeses result in improved clinical outcomes and are at low risk of Popeye deformities, with no statistically significant differences between either method. Additional studies are required to assess the clinical significance of these differences.

Single-Portal Proximal Biceps Tenodesis Using an All-Suture Anchor

The long head of the biceps is an important pain generator of the shoulder joint. Pathologies of the long head of the biceps involve superior labrum anterior to posterior lesions, pulley lesions, partial tears of the biceps tendon, biceps tendonitis, and medial biceps subluxation caused by full-thickness subscapularis tendon tears. Treatment of an inflamed or injured long head of the biceps by either tenotomy or tenodesis is often mandatory during shoulder arthroscopy to avoid persisting pain and possible revision procedures. In comparison with a tenotomy of the biceps tendon, a biceps tenodesis preserves the tension, anatomy, and cosmesis of the biceps muscle. The presented technique demonstrates a single portal technique for a proximal biceps tenodesis in the bicipital groove using an all-suture anchor.

Tenodesis yields better functional results than tenotomy in long head of the biceps tendon operations-a systematic review and meta-analysis

Background

Pathology of the long head of the biceps tendon (LHBT) is a common disorder affecting muscle function and causing considerable pain for the patient. The literature on the two surgical treatment methods (tenotomy and tenodesis) is controversial; therefore, our aim was to compare the results of these interventions.

Methods

We performed a meta-analysis using the following strategy: (P) patients with LHBT pathology, (I) tenodesis, (C) tenotomy, (O) elbow flexion and forearm supination strength, pain assessed on the ten-point Visual Analog Scale (VAS), bicipital cramping pain, Constant, ASES, and SST score, Popeye deformity, and operative time. We included only randomized clinical trials. We searched five databases. During statistical analysis, odds ratios (OR) and weighted mean differences (WMD) were calculated for dichotomous and continuous outcomes, respectively, using the Bayesian method with random effect model.

Results

We included 11 studies in the systematic review, nine of these were eligible for the meta-analysis, containing data about 572 patients (279 in the tenodesis, 293 in the tenotomy group). Our analysis concluded that tenodesis is more beneficial considering 12-month elbow flexion strength (WMD: 3.67 kg; p = 0.006), 12-month forearm supination strength (WMD: 0.36 kg; p = 0.012), and 24-month Popeye deformity (OR: 0.19; p < 0.001), whereas tenotomy was associated with decreased 3-month pain scores on VAS (WMD: 0.99; p < 0.001). We did not find significant difference among the other outcomes.

Conclusion

Tenodesis yields better results in terms of biceps function and is non-inferior regarding long-term pain, while tenotomy is associated with earlier pain relief.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00264-022-05338-9.

Arthroscopic Single-Portal Suprapectoral Biceps Tenodesis With All-Suture Anchor

Tenodesis of the long head of the biceps tendon can be performed through arthroscopic and open techniques with various fixation methods and at different locations on the humerus. Many techniques have been described, with controversy surrounding the advantages and disadvantages of each. In this Technical Note, we describe an all-arthroscopic, intra-articular, single-portal, suprapectoral biceps tenodesis with an all-suture anchor. This technique also allows for suture passage through the biceps tendon before tenotomy to ensure proper maintenance of the length-tension relationship of the biceps musculotendinous unit.

Current Controversies and Decision-Making in the Management of Biceps Pathologies

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Biceps tendon pathologies include a spectrum of injuries that range from mild tendinosis to complete tendon rupture.

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Tendinosis, the most common pathology, occurs more frequently with age and is likely related to chronic degeneration. On the other side of the spectrum of severity lies a rupture of the long head of the biceps tendon (LHBT), which may be accompanied by injury to the glenoid labrum.

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Superior labral anterior-posterior (SLAP) tears are frequently associated with biceps pathology. Surgical management for injuries of the bicipital-labral complex includes biceps tenodesis or tenotomy and SLAP repair. A consensus as to which of these procedures is the optimal choice has not been reached, and management may ultimately depend on patient-specific characteristics.

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Due to the relatively low incidence of distal biceps tendon rupture, agreement on the optimal management strategy has not been reached. Surgical repair, or reconstruction in the case of a chronic rupture, is often chosen. However, nonoperative management has also been utilized in older, less-active patients.

Tenotomy or Tenodesis for Tendinopathy of the Long Head of the Biceps Brachii: An Updated Systematic Review and Meta-analysis

Purpose

The purpose of this meta-analysis was to provide an up-to-date comparison of clinical outcomes of tenotomy and tenodesis in the surgical treatment of long head of the biceps brachii (LHB) tendinopathy.

Methods

A literature search was conducted in EMBASE, Pubmed/Medline and the Cochrane database from January 2000 to May 2020. All studies comparing clinical outcomes between LHB tenotomy and tenodesis were included. Quality was assessed using the Coleman score.

Results

We included 25 studies (8 randomized studies) comprising 2,191 patients undergoing LHB tenotomy or tenodesis, with or without concomitant shoulder procedures (mainly rotator cuff repairs). The Coleman score ranged from 29 to 97 for all studies. When comparing tenodesis and tenotomy in randomized studies, no clinically relevant differences were found in the Constant score (mean difference, 0.9 points), the American Shoulder and Elbow Society Score (mean difference, 1.1 points), shoulder pain (mean difference in visual analogue scale, -0.3 points), elbow flexion strength loss (mean difference, 0%), or forearm supination strength (mean difference, 3%). A Popeye deformity (odds ratio, 0.32) was less commonly seen in patients treated with tenodesis (9% vs 23%).

Conclusion

In our meta-analysis, a Popeye deformity was more frequently observed in patients treated with tenotomy. Based on a substantial number of studies, there is no evidence-based benefit of LHB tenodesis over tenotomy in terms of shoulder function, shoulder pain or biceps-related strength. It is unclear whether LHB tenodesis is of benefit in specific patient groups such as younger individuals.

Level of evidence

Level III, systematic review of level III or higher studies.

Ultrasound-Guided Suprapectoral Tenodesis of the Long Head of the Biceps Brachii

When the long head of the biceps tendon is diseased, tenodesis is an appropriate treatment strategy. The specific technique used is dependent on visualization, fixation method and hardware, and tenodesis location. For suprapectoral tenodesis techniques, those that fix the tendon within or below the bicipital groove can be challenging owing to the transverse humeral ligament covering the groove. To accurately identify the biceps tendon in this area, the ligament often requires resection. Ultrasound provides surgeons with a safe and noninvasive tool to visualize the biceps tendon as it exits the bicipital groove, negating the need for unroofing and other pitfalls associated with traditional techniques. This technical note describes an ultrasound-guided suprapectoral biceps tenodesis procedure.