Arthroscopic biceps tenodesis: a new technique using bioabsorbable interference screw fixation

Return to Sports and Clinical Results After All-Arthroscopic Biceps Tenodesis Using a 2.7-mm Knotless PEEK Suture Anchor

Background

The long head of the biceps tendon (LHBT) is a well-known source of pain in the shoulder, especially in active patients.

Purpose

To evaluate the outcomes and return-to-sports rate after all-arthroscopic suprapectoral tenodesis of the LHBT using a small knotless anchor.

Study Design

Case series; Level of evidence, 4.

Methods

In this retrospective study, 27 patients-who underwent all-arthroscopic tenodesis of the LHBT using a 2.7-mm knotless polyether ether ketone anchor-were evaluated. Sports activities, the return-to-sports rate, and other sports-related parameters (eg, pain during sports, level of sports) were examined. Sports-related data, the Constant score with isometric force (at 90° of abduction in the scapular plane), the American Shoulder and Elbow Surgeons (ASES) score, the Simple Shoulder Test (SST) score, the visual analog scale (VAS) score for satisfaction, range of motion, and the presence of a Popeye deformity were assessed at a mean follow-up of 15.3 ± 8.7 months. The data were initially analyzed using descriptive statistics.

Results

The postoperative ASES, Constant, and SST scores were 81.61, 85.74 and 8.85, respectively. Of the 27 patients, 4 patients (14.8%) showed a Popeye deformity. Preoperatively, 25 patients (92.6%) participated regularly in some type of sports activity. All 25 patients (100.0%) were able to return to sports activities after surgery. 24 (96.0%) returned to the same level preoperatively, with 88.0% (22/25) within 6 months. Patient satisfaction with the outcome was high (VAS score: 2.15 ± 2.78). Neither bicipital groove pain nor cramping was reported. There were no signs of osteolytic bone around the anchor or a fracture of the humeral bone.

Conclusion

Our clinical results after using a 2.7-mm knotless anchor for LHBT tenodesis as well as the return-to-sports rate were satisfying. Using an anchor this size can lower the risk of cortical bone damage and therefore the risk of fractures of the humeral head while still enabling patients to perform at a high level.

Arthroscopic biceps tenodesis using press-fit bony plug: a case series study

PURPOSE

To assess the feasibility, operative time, clinical outcomes, possible complications, and failure rates of all-through arthroscopic biceps tenodesis using press-fit bony plug technique.

METHODS

This prospective case series study involved 30 skeletally mature patients with long head of biceps pathology (tendinitis after failure of conservative treatment, subluxation, dislocation, or tendon tears). All patients were followed up for 24 months at least.

RESULTS

Twenty-nine patients regained full shoulder and elbow range of motion; one case suffered from reflex sympathetic dystrophy. There was a significant improvement in the constant, ASES, and VAS scores when comparing the pre-operative and post-operative values. The average biceps strength was 96% compared to the opposite healthy side. No cases were complicated by neuro-vascular deficits or failure of the tenodesis.

CONCLUSION

Press-fit biceps tenodesis is safe and accessible with low economic demands. We recommend this technique to be used more often when addressing patients with long head of biceps pathologies.

REGISTRATION DATA

Registration number: N-1562023. Registration date: June 2022 "Retrospectively registered".

The double-lasso loop technique of Biceps tenodesis has lower displacement after cyclic loading, compared to interference screw fixation: Biomechanical analysis in an ovine model

Background

Biceps tenodesis is an effective treatment for symptomatic long head of biceps tendon pathology. Recently the arthroscopic "double lasso-loop" suture anchor (DLSA) technique was described, advantaged by reduced cost, complexity, and operative time. We aimed to compare the in vitro strength of DLSA with conventional interference screws (IS).

Methods

A biomechanical analysis was conducted on 14 sheep shoulders (8 DLSA, 6 IS), consisting of a 500-cycle cyclic loading experiment of 5-70 N and ultimate failure load (UFL) test where each specimen was pulled until failure. Displacement (mm) was recorded every 100 cycles, while stiffness and UFL were observed.

Results

Cyclic displacement was significantly lower with DLSA at 100 cycles, but not above. During the UFL test, IS was stiffer (27.68 ± 6.56 N/mm versus 14.10 ± 5.80 N/mm, p = .005) and had higher UFL (453.67 ± 148.55 N versus 234.22 ± 44.57 N, p = .001) than DLSA. All DLSA failures occurred with suture/anchor pull-out, while all IS constructs failed at the muscle/tendon.

Discussion

Comparison of the novel DLSA technique with a traditional IS method found lower initial displacement. While our IS constructs could withstand higher UFL, peak load characteristics of DLSA were similar to previous ovine studies. Hence, the DLSA technique is a viable alternative to IS for biceps tenodesis with its purported non-biomechanical advantages.

Does forearm position matter in subpectoral biceps tenodesis? A randomised controlled trial

INTRODUCTION

The optimal position of the elbow and forearm during biceps tenodesis is a debated topic. The aim of our study was to compare two different forearm positions, pronation-extension (PE) or neutral, for fixation of the long head of the biceps tendon (LHB) in biceps tenodesis.

MATERIALS AND METHODS

Fifty patients who underwent shoulder arthroscopy between February 2016 and January 2019 were included in our study. After diagnostic arthroscopy, the LHB was cut from its origin with a thermal ablator. The LHB was then tenodesed beneath the inferior border of the pectoralis major tendon for 25 patients in the PE position and for 25 patients in the neutral position. Patients were evaluated preoperatively and 3rd, 6th and 12th months postoperatively according to the visual analog scale (VAS), American Shoulder and Elbow Surgeons (ASES) shoulder and Constant scores. Flexion and supination force measurements were made with a digital dynamometer device, compared to the healthy side for both groups.

RESULTS

ASES and VAS scores were statistically better in the PE group compared with the neutral group (p < 0.05), but there was no statistically significant difference between Constant scores at 3 and 6 months (p > 0.05). No significant difference was found in both groups for 3 scores at 12 months. Comparison of the PE group with the contralateral extremity and comparing the neutral group with the contralateral extremity in terms of flexion strength showed no statistically significant difference. No statistically significant difference was found between the supination powers of both comparative groups.

CONCLUSION

Functional scoring in the PE position is better at 3 and 6 months because patients experience less pain at 3 and 6 months. The simple change of the fixation position causes patients to feel less pain in the early period.

LEVEL OF EVIDENCE: 1

The Proximity of the Axillary Nerve During Keyhole Tenodesis of the Long Head of the Biceps Tendon: A Cadaveric Study

Background

Over time, surgical management for conditions involving the long head of the biceps tendon (LHBT) has evolved. Some techniques, such as keyhole tenodesis proposes bicortical drilling, however, carries an axillary nerve injury risk. The goal of our cadaveric study was to see if we could keep a safe zone between the point of exit of keyhole tenodesis of biceps and axillary nerve.

Methodology

The study was performed on ten shoulders from five fresh frozen cadavers. Between the lower border of the transverse humeral ligament (THL) and the superior margin of the pectoralis major insertion at the lowest limit of the bicipital groove, a beath pin was driven through with the help of the modified tip aimer tibial jig procured from the anterior cruciate ligament reconstruction (ACL) set, which was fixed at an arc of 45°. The distance between the axillary nerve and beath pin at the exit point was measured.

Results

The biceps tendon musculotendinous junction was followed all the way to the inferiorly and biceps tendon was found in the groove. The average distance from the axillary nerve to the exit point of the beath pin was 17.7 mm (range 14.4-20.9 mm, 95% CI).

Conclusion

The axillary nerve is not injured during bicortical drilling when keyhole tenodesis of biceps is performed at the distal limit of the groove of biceps. The area in the biciptal groove between inferior margin of THL and superior border of pectoralis major insertion is safe area for biceps tenodesis.

Biceps Tenodesis Versus Superior Labral Anterior and Posterior (SLAP) Lesion Repair for the Treatment of SLAP Lesion in Overhead Athletes: A Systematic Review and Meta-analysis

BACKGROUND

Superior labral anterior and posterior (SLAP) lesions are common injuries in overhead athletes. As a surgical treatment for SLAP lesions, SLAP repair has been traditionally performed. Recently, biceps tenodesis has been performed as an alternative treatment option; however, there is no review for outcome comparisons between these 2 procedures in overhead athletes.

PURPOSE

The aim of this study was to compare the outcomes of SLAP repair versus biceps tenodesis, especially in overhead athletes with SLAP lesions.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 4.

METHODS

An electronic literature search was performed in Medline, Embase, Scopus, and the Cochrane Library. The studies were appraised using the Methodological Index for Non-randomized Studies (MINORS) tool. Studies that had a minimum follow-up of 2 years, included only patients with SLAP lesions without other major shoulder pathologies, and included only patients who engaged in overhead sports were included. The functional outcomes of the American Shoulder and Elbow Surgeons (ASES) score, rate of return to sport, rate of return to preinjury level of sport, and complication rate were subjected to meta-analysis.

RESULTS

A total of 332 articles were identified, and 13 were included in the systematic review. Even though the postoperative ASES scores were slightly higher in the biceps tenodesis group than in the SLAP repair group, no statistically significant differences were found between the groups (biceps tenodesis, 95% CI = 91.71-96.75, I² = 0.00; SLAP repair, 95% CI = 85.47-94.46, I² = 16.3; P = .085) The rate of return to sport and the return to preinjury level of sport were slightly higher in the biceps tenodesis group than in the SLAP repair group; however, in meta-analysis these factors did not reach statistical significance (return to sport: biceps tenodesis, 95% CI = 0.66-0.91, I² = 0.00; SLAP repair, 95% CI = 0.68-0.93, I² = 70.23; P = .94) (return to preinjury level of sport: biceps tenodesis, 95% CI = 0.61-0.89, I² = 17.78; SLAP repair, 95% CI = 0.53-0.82, I² = 58.07; P = .37). The biceps tenodesis group showed a lower complication rate compared with the SLAP repair group without statistical significance (biceps tenodesis, 95% CI = 0.013-0.145, I² = 0.00; SLAP repair, 95% CI = 0.049-0.143, I² = 0.00; P = .25).

CONCLUSION

The results of biceps tenodesis, compared with SLAP repair, were not inferior in the surgical treatment of overhead athletes with SLAP lesions with regard to the ASES score, rate of return to sport, rate of return to preinjury level of sport, and complication rate. Further high-level, randomized controlled studies are needed to confirm this result.

[Postoperative imaging of the shoulder]

BACKGROUND

Imaging of the postoperative shoulder joint includes complex, diagnostically challenging changes regarding the anatomical structures.

OBJECTIVES

Case-based presentation of common surgical procedures, expected postoperative findings, and typical complications.

MATERIALS AND METHODS

Interdisciplinary evaluation of (didactically instructive) cases and discussion of pertinent literature and expert opinions.

RESULTS

Presentation of normal postoperative findings and complications after subacromial decompression, surgical treatment of rotator cuff lesions, SLAP (superior labral anterior to posterior) lesions/lesions of the long biceps tendon, Bankart lesions as well as instability-related procedures and after shoulder arthroplasty. Discussion of the appropriate use of imaging methods with a focus on magnetic resonance imaging (MRI), which are supplemented by computed tomography (CT), and conventional x‑ray images.

CONCLUSION

The broad spectrum of complex findings as well as the evermore developing and thereby changing surgical procedures result in significant challenges in the radiological evaluation of the postoperative shoulder joint. To differentiate physiological reactions from pathological changes it is necessary to have general knowledge of the common surgical procedures, expected postoperative findings and possible complications. A variety imaging modalities can be used to further advance diagnostic precision.

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.

Anterior glenohumeral capsular ligament reconstruction with hamstring autograft for internal impingement with anterior instability of the shoulder in baseball players: preliminary surgical outcomes

BACKGROUND

Shoulder pain and dysfunction are common in baseball players, and although "internal impingement" is recognized as one of the most common pathologies of shoulder dysfunction, the optimal surgical treatment for internal impingement with anterior instability of the shoulder remains controversial. This study evaluated baseball players' preliminary outcomes following anterior glenohumeral capsular ligament reconstruction for internal impingement with anterior instability of the shoulder.

METHODS

Twelve baseball players (all male; mean age, 20.5 ± 2.2 years) with internal impingement and anterior instability managed via anterior glenohumeral capsular ligament reconstruction were examined. The mean follow-up period was 25.3 ± 4.6 months. Anterior glenohumeral capsular ligament reconstruction was performed with a knee hamstring autograft for balanced stability and laxity with two major targets: to prevent hyperangulation and translation in horizontal abduction and to mimic the individual arm cocking position at the final decision of tension. Preoperative and final follow-up evaluations were performed using Jobe's postoperative grading system; the Kerlan-Jobe Orthopaedic Clinic Overhead Athletes Shoulder and Elbow Score; Disabilities of the Arm, Shoulder and Hand sports module; plain radiographs; and magnetic resonance imaging.

RESULTS

Jobe's postoperative grading system score, the Kerlan-Jobe Orthopaedic Clinic Overhead Athletes Shoulder and Elbow Score, and the Disabilities of the Arm, Shoulder and Hand sports module score improved significantly from 20.4 ± 12.2, 28.4 ± 8.3, and 80.2 ± 11.1 points preoperatively to 88.8 ± 13.6, 80.8 ± 7.7, and 22.4 ± 18.7 points postoperatively, respectively (P < .001, .0025, <0.001, respectively). Both clinical and imaging evaluations revealed improved internal impingement with anterior instability after anterior glenohumeral capsular ligament reconstruction. The mean external rotation at abduction significantly decreased from 113° preoperatively to 104° postoperatively. At follow-up, 10 of the 12 athletes (83.3%) returned to their prior competitive level. Plain radiographs and magnetic resonance imaging revealed no obvious loosening of the graft or screws.

CONCLUSIONS

Anterior glenohumeral capsular ligament reconstruction resulted in preferable clinical outcomes for young baseball players who experienced pain during the throwing motion. Stabilization of the glenohumeral joint with autografting of the knee hamstring may thus represent a solution for internal impingement with anterior instability in overhead throwing athletes.

Subpectoral Biceps Tenodesis Using an All-Suture Anchor

Long head biceps tendon pathology is a substantial contributor to anterior shoulder pain and often requires surgical intervention to offer a return to normal functionality. Surgical treatment options consist of both open and arthroscopic tenodesis or tenotomy of the long head biceps brachii. Several techniques exist for tenodesis and tenotomy of the biceps, although current debate continues regarding which surgical approach is the optimal intervention for symptomatic bicep pathology. In this technical note, we describe a subpectoral biceps tenodesis of the long head bicep tendon using an all-suture anchor. Our technique offers the advantages of using an all-suture anchor that incorporates a self-tensioning mechanism with direct visualization of the tendon during biceps tenodesis and anchor insertion.

The "Not" Good, the Bad and the Ugly: Prevention and Management of Common Intraoperative and Delayed Complications in Orthopedic Sports Medicine Surgical Procedures

Despite advances in techniques designed to make arthroscopic sports medicine procedures simple, complications still arise in the operating room; even in the most trained hands. However, what marks a skilled surgeon is not just the ability to steer the ship amidst smooth seas, but a knack for getting out of trouble once things deviate from the set course. Each surgical case presents a unique challenge, and no 2 are the same. For this reason, a true expert surgeon must know how to deal with "complications" ranging from a mild swell to a raging storm. In this review we present strategies to prevent and navigate some of the most common, and fearsome complications a sports medicine surgeon may face during surgery. A great surgeon is one that acknowledges that throughout their career it is not a question of "if" these situations will arise, but "when"; and preparation is the key to success.

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.

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.

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

»

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

»

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.

»

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.

»

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.

Clinical Outcomes of Revision Biceps Tenodesis for Failed Long Head of Biceps Surgery: A Systematic Review

PURPOSE

We summarize the indications, assess the modes of failure, and analyze the clinical and functional outcomes of revision biceps tenodesis after failed primary surgical treatment of long head of biceps (LHB) pathology.

METHODS

A computerized search of PubMed, EMBASE, and CINAHL databases and manual screening of selected article reference lists was performed in September 2020. Randomized controlled trial, cohort, case-control, and case series studies reporting clinical outcomes of revision biceps tenodesis following failed LHB surgery were eligible. Patient demographics, indications for revision, intraoperative findings, surgical techniques, and patient-reported outcomes were recorded. Functional assessment and pain scores were assessed and summarized as forest plots with means and 95% confidence intervals.

RESULTS

Five of 465 identified studies met inclusion criteria, encompassing 70 revision biceps tenodesis procedures with mean follow-up of 2.4-6.4 years. The failed index procedure was biceps tenodesis in 62 patients and tenotomy in 8 patients. The most common indications for revision were pain or cramping and rerupture, cited by 4 and 3 articles, respectively. After failed conservative treatment, open subpectoral revision tenodesis was performed with concomitant arthroscopic debridement in 65 of 70 cases. Common intraoperative findings at time of revision were adhesions or scarring (39.0-83.0%), fixation failure (8.7-75.0%), and biceps rupture (17.4-80.0%). Revision tenodesis patients reported good to excellent functional outcomes with improvements in Single Assessment Numeric Evaluation, American Shoulder and Elbow Surgeons Shoulder, and visual analog scale pain scores, and satisfaction ranged from 88.0 to 100%. All studies demonstrated moderate quality of evidence and risk of bias when critically appraised.

CONCLUSION

This systematic review of 5 moderate risk of bias studies demonstrated that the most common reasons for revision biceps tenodesis were pain or cramping and rerupture. Open subpectoral revision tenodesis with concomitant arthroscopic debridement provided improvements in functional scores with high patient satisfaction at mid-term follow up.

LEVEL OF EVIDENCE

IV, Systematic Review of level III and IV investigations.

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.

The rate and reporting of fracture after biceps tenodesis: A systematic review

BACKGROUND

The purpose of this systematic review was to (1) define the cumulative humerus fracture rate after BT and (2) compare how often fracture rate was reported compared to other complications.

METHODS

A systematic review was performed using the PRISMA guidelines.

RESULTS

39 studies reported complications and 30 reported no complications. Of the 39 studies that reported complications, 5 studies reported fracture after BT (n = 669, cumulative incidence of 0.53%). The overall non-fracture complication rate was 12.9%.

DISCUSSION

Due to the relatively high incidence of fracture, surgeons should ensure that this complication is disclosed to patients undergoing BT.

The Injured Shoulder in High-Level Male Gymnasts, Part 2: Can Athletes Return to Competition After Surgery?

BACKGROUND

The results of surgical treatment of shoulder injuries in high-level male gymnasts have not yet been documented.

PURPOSE

To evaluate the functional and subjective results after surgical treatment of shoulder injuries in high-level gymnasts and the possibilities to return to sport at the same level.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Over a 20-year period (1994-2014), 23 high-level male gymnasts (26 shoulders) underwent surgery by a single experienced shoulder surgeon. At the time of surgery, 7 gymnasts competed at the international level, 12 at the national elite level, and 4 at the regional level. According to symptoms and anatomic lesions, the shoulders were classified into 2 groups: painful shoulders (n = 11) and unstable shoulders (n = 15). Fifteen capsulolabral repairs, 10 cuff debridements, 1 cuff repair, 4 SLAP (superior labral anterior and posterior) repairs, and 8 suprapectoral biceps tenodesis were performed. Twelve shoulders (46%) had >1 procedure performed. Outcomes assessment was performed by an independent observer at a mean of 5 years (range, 2-15 years) postoperatively. In addition, patients completed the Subjective Shoulder Value (range, 0%-100%).

RESULTS

After shoulder surgery, 21 (91%) of the 23 gymnasts returned to competitive gymnastics, and 20 gymnasts (87%) regained their preinjury level of sport. All international-level gymnasts returned to their preinjury level of sport. Three athletes (13%) underwent revision surgery, and 1 athlete (4%) ended his career without returning to competition. The postoperative period before resumption of competitive gymnastics was 9 ± 3.5 months (mean ± SD). Of the 15 gymnasts treated for shoulder instability with arthroscopic stabilization, 12 were able to return to their previous level of sport. All 8 gymnasts who had arthroscopic biceps tenodesis were able to return to their previous level of sport, as opposed to only 2 of 4 gymnasts treated with SLAP repair. The gymnastics-specific Subjective Shoulder Value score was 80% ± 11%.

CONCLUSION

Most gymnasts who required surgical treatment for a shoulder injury were able to return to competition at their previous level, although there was a considerable postoperative recovery period. Current arthroscopic reconstruction techniques were effective for treating structural lesions and allowing return to high-level gymnastics.

Surgical Management of Superior Labral Tears in Athletes: Focus on Biceps Tenodesis

Superior labrum anterior-posterior (SLAP) lesions are common in overhead athletes. Though some patients have asymptomatic lesions, many tears cause pain and diminished athletic performance. Accurate diagnosis of SLAP lesions can be challenging as the sensitivity and specificity of both the physical exam and advanced imaging is questionable. Management is also difficult, as treatment can be life-altering or career-ending for many athletes. If first-line nonoperative treatment fails, surgical options may be considered. The optimal surgical management of SLAP lesions in athletes is debated. Historically, return to play (RTP) rates among athletes who have undergone arthroscopic SLAP repair have been unsatisfactory, prompting clinicians to seek alternate surgical options. Biceps tenodesis (BT) has been postulated to eliminate biceps tendon-related pain in the shoulder and is increasingly used as a primary procedure for SLAP lesions. The purpose of this text is to review the current literature on the surgical management of SLAP lesions in athletes with an emphasis on the role of BT.

Early success of the arthroscopic-assisted locked loop suprapectoral biceps tenodesis

Background

There is wide variability in surgical technique for biceps tenodesis. Prior biomechanical studies have demonstrated superior ultimate and fatigue strength with a Krakow-type locked loop when compared with simple suture and lasso-loop configurations; however, this had not yet been clinically studied. The purpose of this study was to assess the short-term results an arthroscopic-assisted locked loop (ALL) suprapectoral biceps tenodesis technique.

Methods

All patients who underwent an ALL suprapectoral biceps tenodesis by a single surgeon from 2012 and 2019 with a minimum of 12-month follow-up were analyzed. Data collected included demographics, surgical indications, concomitant operative procedures, and postoperative complications of anterior shoulder "groove" pain, "Popeye deformity," biceps muscle cramping pain, and need for revision surgery.

Results

Forty patients who underwent an ALL suprapectoral biceps tenodesis met inclusion criteria. Patients were 55.6 ± 8.6 years of age, consisting of 28 men (57%) and 21 women (43%). The median follow-up was 19.3 months. At the latest follow-up, 1 (2%) patient had anterior shoulder "groove" pain, and no patients had a Popeye deformity or biceps muscle cramping. There were no revision biceps tenodesis procedures.

Conclusion

The ALL suprapectoral biceps tenodesis technique results in a low incidence of postoperative complications. At a short-term follow-up of 1 year, no patients had reoperations or revisions for failed biceps tenodesis. Groove pain was nearly absent in this series of patients.

Biceps Tenodesis for Superior Labrum Anterior-Posterior Tear in the Overhead Athlete: A Systematic Review

BACKGROUND

Superior labrum anterior-posterior (SLAP) lesion is a common shoulder injury, particularly in overhead athletes. While surgical management has traditionally consisted of SLAP repair, high rates of revision and complications have led to alternative techniques, such as biceps tenodesis (BT). While BT is commonly reserved for older nonoverhead athletes, indications for its use have expanded in recent years.

PURPOSE

To determine functional outcomes and return-to-sport rates among overhead athletes after BT for SLAP tear.

STUDY DESIGN

Systematic review.

METHODS

A systematic review was performed for any articles published before July 2019. The search phrase "labral tear" was used to capture maximum results, followed by keyword inclusion of "SLAP tear" and "biceps tenodesis." Inclusion criteria included outcome studies of BT for isolated SLAP tear in athletes participating in any overhead sports, not limited to throwing alone. Abstracts and manuscripts were independently reviewed to determine eligibility. When clearly delineated, outcome variables from multiple studies were combined.

RESULTS

After full review, 8 articles met inclusion criteria (99 athletes; mean age, 19.8-47 years), with baseball and softball players the most common among them (n = 62). Type II SLAP tear was the most common diagnosis, and 0% to 44% of athletes had a failed previous SLAP repair before undergoing BT. Only 1 study included patients with concomitant rotator cuff repair. Open subpectoral BT was most commonly used, and complication rates ranged from 0% to 14%, with wound erythema, traumatic biceps tendon rupture, brachial plexus neurapraxia, and adhesive capsulitis being reported. Combined reported postoperative functional scores were as follows: American Shoulder and Elbow Surgeons, 81.7 to 97; 12-Item Short Form Health Survey physical, 50 to 54; visual analog scale for pain, 0.8-1.5; Kerlan Jobe Orthopaedic Clinic, 66 to 79; and satisfaction, 80% to 87%. The overall return-to-sports rate for overhead athletes was 70% (60 of 86). For studies that clearly delineated outcomes based on level of play/athlete, the combined return-to-sports rate was 69% (11 of 16) for recreational overhead athletes, 80% (4 of 5) for competitive/collegiate athletes, and 60% (18 of 30) for professionals.

CONCLUSION

BT in the overhead athlete offers encouraging functional outcomes and return-to-sports rates, particularly in the recreational athlete. It can be successfully performed as an index operation rather than SLAP repair, as well as in a younger patient population. Careful consideration should be given to elite overhead athletes, particularly pitchers, who tend to experience poorer outcomes.

The Top 50 Most-Cited Shoulder Arthroscopy Studies

Purpose

To determine the 50 most frequently cited studies in the orthopaedic shoulder arthroscopy literature and to conduct a bibliometric analysis of these studies.

Methods

The Clarivate Analytics Web of Knowledge database was used to gather data and metrics using Boolean queries to capture all possible iterations of shoulder arthroscopy research. The search list was sorted so that articles were organized in descending order based on the number of citations and included or excluded based on relevance to shoulder arthroscopy. The information extracted for each article included author name, publication year, country of origin, journal name, article type, and the level of evidence.

Results

For these 50 studies, the total number of citations was calculated to be 13,910, with an average of 278.2 citations per paper. The most-cited article was cited 1134 times, whereas the second- and third-most cited articles were cited 920 and 745 times, respectively. All 50 articles were published in English and came from 7 different orthopaedic journals. The United States was responsible for most of the included articles (31), followed by France (9) and Japan (3).

Conclusions

The majority of the most-cited articles in shoulder arthroscopy are case series and descriptive studies originating from the United States. In addition, more than one half of the top 50 most-cited studies were published after 2004, which suggests that article age may be less important in the accumulation of citations for a rapidly growing field like shoulder arthroscopy.

Clinical Relevance

The top 50 most-cited studies list will provide researchers, medical students, residents, and fellows with a foundational list of the most important and influential academic contributions to shoulder arthroscopy.

Measurements of Tendon Movement Within the Bicipital Groove After Suprapectoral Intra-articular Biceps Tenodesis in a Cadaveric Model

Background

Lesions of the long head of the biceps can be successfully treated with biceps tenotomy or tenodesis when surgical management is elected. The advantage of a tenodesis is that it prevents the potential development of a cosmetic deformity or cramping muscle pain. Proponents of a subpectoral tenodesis believe that "groove pain" may remain a problem after suprapectoral tenodesis as a result of persistent motion of the tendon within the bicipital groove.

Purpose/Hypothesis

To evaluate the motion of the biceps tendon within the bicipital groove before and after a suprapectoral intra-articular tenodesis. The hypothesis was that there would be minimal to no motion of the biceps tendon within the bicipital groove after tenodesis.

Study Design

Controlled laboratory study.

Methods

Six fresh-frozen cadaveric arms were dissected to expose the long head of the biceps tendon as well as the bicipital groove. Inclinometers and fiducials (optical markers) were used to measure the motions of the scapula, forearm, and biceps tendon through a full range of shoulder and elbow motions. A suprapectoral biceps tenodesis was then performed, and the motions were repeated. The motion of the biceps tendon was quantified as a function of scapular or forearm motion in each plane, both before and after the tenodesis.

Results

There was minimal motion of the native biceps tendon during elbow flexion and extension but significant motion during all planes of scapular motion before tenodesis, with the most motion occurring during shoulder flexion-extension (20.73 ± 8.21 mm). The motion of the biceps tendon after tenodesis was significantly reduced during every plane of scapular motion compared with the native state (P < .01 in all planes of motion), with a maximum motion of only 1.57 mm.

Conclusion

There was a statistically significant reduction in motion of the biceps tendon in all planes of scapular motion after the intra-articular biceps tenodesis. The motion of the biceps tendon within the bicipital groove was essentially eliminated after the suprapectoral biceps tenodesis.

Clinical Relevance

This arthroscopic suprapectoral tenodesis technique can significantly reduce motion of the biceps tendon within the groove in this cadaveric study, possibly reducing the likelihood of groove pain in the clinical setting.

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.

A Systematic Review and Meta-analysis of Biceps Tenodesis Fixation Strengths: Fixation Type and Location Are Biomechanically Equivalent

PURPOSE

The purpose of this meta-analysis and systematic review was to critically evaluate the biomechanical outcomes of different fixation constructs for a variety of biceps tenodesis techniques in cadaveric models based on both type of fixation and location.

METHODS

A PROSPERO-registered systematic review (CCRD42018109243) of the current literature was conducted with the terms "long head of biceps" AND "tenodesis" AND "biomechanics" and numerous variations thereof in the PubMed, Embase, and Cochrane databases, yielding 1,460 abstracts. After screening by eligibility criteria, 18 full-text articles were included. The individual biomechanical factors evaluated included ultimate load to failure (in newtons), stiffness (in newtons per millimeter), and cyclic displacement (in millimeters). After reviewing the included literature, we performed a quality analysis of the studies (Quality Appraisal for Cadaveric Studies scale score) and a meta-analysis comparing raw mean differences in data between the suprapectoral and subpectoral fixation location groups, as well as between the fixation construct groups.

RESULTS

Among the 18 included studies, 347 cadaveric specimens were evaluated for ultimate load to failure, stiffness, and cyclic displacement when comparing both location (suprapectoral vs subpectoral) and tenodesis fixation type (interference screw vs cortical button, suture anchor, or all-soft-tissue techniques). Interference screw fixation showed significantly greater mean stiffness by 8.0 N/mm (P = .013) compared with the other grouped techniques but did not show significant differences when evaluated for ultimate load to failure and cyclic displacement (P = .28 and P = .18, respectively). Additionally, no difference in construct strength was seen when comparing the fixation strength of suprapectoral versus subpectoral techniques for stiffness, ultimate load to failure, and cyclic loading (P = .47, P = .053, and P = .13, respectively).

CONCLUSIONS

In this meta-analysis, no significant biomechanical differences were found when the results were stratified by specific surgical technique (interference screw vs other tenodesis techniques) and location (suprapectoral vs subpectoral biceps tenodesis).

CLINICAL RELEVANCE

As a result of this study, when biomechanically evaluating specific tenodesis constructs, the individual clinician has the liberty of choosing the fixation technique based on his or her preference and knowledge of shortcomings of each type of fixation construct.

Arthroscopic Biceps Tenodesis Outcomes: A Comparison of Inlay and Onlay Techniques

BACKGROUND

Arthroscopic biceps tenodesis (ABT) high in the groove can be achieved using an inlay or an onlay technique. However, there is little information comparing outcomes between the 2.

PURPOSE

To compare postoperative healing and functional outcomes of ABT high in the groove performed using either an onlay or an inlay technique.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective study was performed on patients undergoing ABT at the articular margin (high in the groove) at a single center over a 2-year period. An inlay technique using an interference screw was performed during the first year, followed by an onlay technique using a knotless suture anchor during the second. Tendon healing, elbow flexion strength, functional outcome, and complications were evaluated at a postoperative minimum of 1 year.

RESULTS

A total of 37 patients with inlay and 53 with onlay ABTs were available for follow-up. There was no difference in range of motion, functional outcome scores, or elbow flexion strength between the groups. A postoperative popeye deformity was noted in 27% of patients in the inlay group as compared with 9.4% of the onlay group (P = .028). Four patients (10.8%) in the inlay group required revision surgery (2 of which were biceps tenodesis related) as compared with 0% in the onlay group (P = .015).

CONCLUSION

An onlay technique using a knotless suture anchor for ABT at the top of the articular margin is an acceptable alternative to an inlay technique using an interference screw. The onlay technique was associated with lower rates of postoperative popeye deformity and revision surgery as compared with the inlay technique.

Anatomic limitations of biceps tenodesis using an interference screw for Asian people: a cadaveric study

Background

Biceps tenodesis using an interference screw has been commonly performed in clinical practice because of pathologic changes. Especially, the tenodesis distal to the bicipital groove, such as suprapectoral tenodesis (SPT) and subpectoral tenodesis (SBT), has been performed to avoid residual anterior shoulder pain. However, the techniques were developed based on research tested on Western population, and it is unknown whether they are applicable to Asian individuals, who have a smaller humerus than Western. The purpose of this study was to investigate the anatomic limitations of the biceps tenodesis using an interference screw for Asians.

Methods

We analyzed 22 fixed Japanese cadavers. We measured the length of the suprapectoral tenodesis zone (STZ), which is the area from the distal end of the lesser tuberosity to the proximal border of the insertion of the pectoralis major muscle tendon (PMMT) along the course of the biceps tendon, for the SPT. We also measured the bone tunnel depths (BTDs) for the SPT just distal to the lesser tuberosity along the course of the biceps tendon and, similarly, for the SBT just distal to the PMMT insertion. Finally, we analyzed the sexual differences and correlations of the measured values with the entire humeral length.

Results

In 9 shoulders (40.9%), the proximal border of the PMMT insertion was attached more proximally than the distal end of the lesser tuberosity, and the length of the STZ was negative. The mean BTDs in the SPT and SBT zones were 19.6 and 14.9 mm, respectively. In 11 shoulders (50%), the BTD in the SBT zone was shorter than 15 mm. The lengths of the STZ or BTDs in the SPT and SBT zones did not show statistical differences between sexes and were not correlated with the entire humeral length.

Conclusion

Asian patients would have anatomic limitations as follows for the biceps tenodesis regardless of their sex or body size. In anomalous PMMT cases, when the SPT was performed just proximal to the PMMT insertion, the bone tunnel entered into the bicipital groove. On the other hand, when the SPT was performed distal to the lesser tuberosity, a part of the PMMT insertion would be injured. Regarding the SBT, an interference screw with a length of ≥12 mm, which is commonly used in Western countries, is too long for Asians.

What happens to the long head of the biceps tendon after arthroscopic rotator cuff repair?

Aims

The purpose of this study was to identify the changes in untreated long head of the biceps brachii tendon (LHBT) after a rotator cuff tear and to evaluate the factors related to the changes.

Methods

A cohort of 162 patients who underwent isolated supraspinatus with the preservation of LHBT was enrolled and evaluated. The cross-sectional area (CSA) of the LHBT on MRI was measured in the bicipital groove, and preoperative to postoperative difference was calculated at least 12 months postoperatively. Second, postoperative changes in the LHBT including intratendinous signal change, rupture, dislocation, or superior labral lesions were evaluated with seeking of factors that were correlated with the changes or newly developed lesions after rotator cuff repair.

Results

The postoperative CSA (12.5 mm2 (SD 8.3) was significantly larger than preoperative CSA (11.5 mm2 (SD 7.5); p = 0.005). In total, 32 patients (19.8%) showed morphological changes in the untreated LHBT 24 months after rotator cuff repair. Univariate regression analysis revealed that the factor chiefly related to the change in LHBT status was an eccentric LHBT position within the groove found on preoperative MRI (p = 0.011). Multivariate analysis using logistic regression also revealed that an eccentric LHBT position was a factor related to postoperative change in untreated LHBTs (p = 0.011).

Conclusion

The CSA of the LHBT inside the biceps groove increased after rotator cuff repair. The preoperative presence of an eccentrically positioned LHBT was associated with further changes of the tendon itself after rotator cuff repair. Cite this article: Bone Joint J 2020;102-B(9):1194–1199.

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.

Suprapectoral biceps tenodesis with bicortical drilling procedures: anatomic analysis of chondral and axillary nerve risk with transhumeral pin guide

BACKGROUND

Many biceps tenodesis (BT) procedures are described for treating proximal biceps pathology. Axillary nerve injury has been reported during BT using bicortical drilling techniques with variable results depending on the location. In addition, there is a risk of potential articular damage during suprapectoral BT. We sought to determine the distance between the axillary nerve and the posterior passage of a bicortical pin, as well as the risk of articular damage, and to analyze whether a lateral inclination of the pin could avoid the chondral risk during suprapectoral BT with bicortical drilling.

METHODS

Ten cadaveric shoulders were divided into 2 groups. In the first group, we determined the axillary nerve distance from the posterior exit point of 3 pins in a suprapectoral position 15 mm distal to the humeral cartilage: perpendicular, 10° caudal, and 20° caudal inclination. We measured 2 distances from the pin: to the axillary nerve and to the cartilage border. In the second group, we set one pin at the same perpendicular position and set the second pin 15° laterally tilted to determine its extra-articular passage.

RESULTS

No pin injured the nerve, whereas all pins showed a transchondral direction. The 20° caudal inclination was the nearest to the nerve (18.8 mm [95% confidence interval, 5.5-32 mm]), but the perpendicular position was the safer position (38.8 mm [95% confidence interval, 28-49.6 mm]). Tilting the pin direction 15° laterally prevented cartilage damage (P = .008).

CONCLUSIONS

Suprapectoral BT with bicortical drilling performed 15 mm distal to the humeral cartilage is a safe procedure regarding the axillary nerve. A potential humeral chondral injury could be prevented with 15° of lateral inclination of the pin guide.

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

BACKGROUND

Suprapectoral long head biceps (LHB) tenodesis and subpectoral LHB tenodesis are both commonly performed surgical procedures. Due to the more proximal position of the suprapectoral tenodesis site this technique may be accompanied with more postoperative pain in the bicipital groove and cramping pain in the biceps muscle. We hypothesized that subpectoral tenodesis is associated with a better clinical outcome than suprapectoral tenodesis.

METHODS

A literature search was conducted in PubMed and Embase from January 2000 to July 2019 with the terms "biceps" and "tenodesis". Only comparing studies reporting on American Shoulder Elbow Score (ASES), VAS for anterior shoulder pain, Constant Murley Score (CMS), pain in the bicipital groove and Popeye deformity following suprapectoral and subpectoral tenodesis were included. Quality assessment of included articles was performed using the Coleman score.

RESULTS

Seven comparative studies with 409 patients reporting the results of LHB suprapectoral and subpectoral tenodesis were included. A significant, but clinically irrelevant difference in ASES (mean difference 2.15) p=0.01 was observed. No significant difference in CMS (mean difference 0.09), VAS for anterior shoulder pain (mean difference 0.01), Popeye deformity (odds ratio 3.19) and persistent bicipital pain (odds ratio 2.66). The Coleman score ranged between 53 and 87.

CONCLUSION

Based on this meta-analysis we found a significantly, though not clinically relevant difference in ASES in favour of subpectoral LHB tenodesis when compared with suprapectoral LHB tenodesis. Comparable results were found with regard to outcome scores, pain in the bicipital groove and avoiding a Popeye deformity.

Intra-articular arthroscopic biceps tenodesis with interference screw: clinical and isokinetic evaluation

Background

Although biceps tenodesis has been widely used to treat its pathologies, few studies looked at the objective evaluation of elbow strength after this procedure. The purpose of this study is to clinically evaluate patients submitted to long head of the biceps (LHB) tenodesis with interference screws through an intra-articular approach and analyze the results of an isokinetic test to measure elbow flexion and forearm supination strengths.

Methods

Patients who had biceps tenodesis were included in the study if they had a minimum follow-up of 24 months. Patients were excluded if they had concomitant irreparable cuff tears or previous or current contralateral shoulder pain or weakness. Postoperative evaluation was based on University of California-Los Angeles (UCLA) shoulder score and on measurements of elbow flexion and supination strength, using an isokinetic dynamometer. Tests were conducted in both arms, with velocity set at 60º/s with 5 concentric-concentric repetitions.

Results

Thirty-three patients were included and the most common concomitant diagnosis were rotator cuff tear (69%) and superior labrum anterior to posterior (SLAP) lesions (28%). The average UCLA score improved from 15.1 preoperatively to 31.9 in the final follow-up (P < .001). Isokinetic tests showed no difference in peak torque between the upper limbs. One patient had residual pain in the biceps groove. None of the patients had Popeye deformity. UCLA score and follow-up length did not demonstrate correlation with peak torque.

Conclusion

Arthroscopic proximal biceps tenodesis with interference screw, close to the articular margin, yielded good clinical results. Isokinetic tests revealed no difference to the contralateral side in peak torque for both supination and elbow flexion.

Arthroscopic tenodesis using a bioabsorbable interference screw and soft anchor: A case series of 60 patients

BACKGROUND

Various arthroscopic tenodesis techniques for the treatment of long head of the biceps tendon pathologic abnormalities have been described.

PURPOSE

This study evaluated the clinical outcomes of using a bioabsorbable interference screw and soft anchor for long head of the biceps tendon arthroscopic tenodesis.

METHODS

Sixty patients treated by this technique between February 2013 and March 2015 were followed up for at least 2 years. In our operative technique, after the bone hole was made just proximal to the pectoralis major, the soft anchor was inserted at the bottom of the hole. After tenotomy of the long head of the biceps tendon proximal to the bone hole, the tendon was fixed into the bottom of the hole temporarily using the soft anchor. Finally, the tendon was fixed in the hole with a bioabsorbable interference screw.

RESULTS

The UCLA score 15.1 points preoperatively and 32.4 points at follow-up (p < 0.05). The Constant 55.8 points preoperatively and 93.9 points at follow-up (p < 0.01). After biceps tenodesis, no cosmetic deformities were found in 56 patients (93.3%), and four patients (6.7%) had a Popeye deformity. On postoperative magnetic resonance evaluation, the long head of the biceps tendon was located on the bicipital groove without deviation in 53 cases (88.3%), on the bicipital groove with a partial deviation in 6 cases (10.0%), and outside the bicipital groove with complete deviation (dislocated) in 1 case (1.7%).

CONCLUSION

We found that arthroscopic biceps tenodesis using a soft anchor provided a reliable means for treating biceps pathology with no cosmetic deformities and with good clinical results.

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

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

RESULTS

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

CONCLUSION

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

REGISTRATION

NCT01747902 ( ClinicalTrials.gov identifier).

Should long head of biceps tenodesis or tenotomy be routinely performed in arthroscopic rotator cuff repairs?

Purpose

The long head of the biceps tendon (LHBT) lesions are frequently associated with partial or complete rotator cuff tears (RCTs), but controversy revolves around their optimal surgical management.

Methods

Hence this article aims to review the current literature available on the role of biceps surgery in rotator cuff surgery and whether it should be routinely performed in rotator cuff repairs.

Results

Furthermore, we also discuss the advantages and drawbacks of tenotomy or tenodesis of LHBT in rotator cuff surgery.

Conclusion

We conclude this article with recommendations for surgeons performing rotator cuff repairs and future research in this area.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

LEVEL OF EVIDENCE

Level IV, case series.

Case-control comparison of "in-the-groove" and lateral-row arthroscopic biceps tenodesis with concomitant rotator cuff repair

Background

Lateral-row (LR) arthroscopic biceps tenodesis (BT) has been described as a technique using an LR rotator cuff repair (RCR) anchor for biceps fixation. This technique has not been compared with other BT techniques. The purpose of this study was to compare the clinical outcomes of patients undergoing a suprapectoral "in-the-groove" arthroscopic BT and patients treated with an LR tenodesis performed in conjunction with arthroscopic RCR.

Methods

Patients undergoing arthroscopic BT in the setting of an arthroscopic RCR were evaluated preoperatively and at a minimum of 12 months' follow-up. Patients who underwent an in-the-groove BT were matched 1:1 to patients who underwent an LR BT based on age at surgery and size of the rotator cuff tear using the Patte classification. Comparisons made included age, sex, body mass index, patient-reported outcome measures, range of motion, and patient satisfaction.

Results

There were 82 patients (41 in each group) who met the inclusion criteria, with an average follow-up period of 33 months and average age of 61 years. By use of the Patte classification, there were 20 matched pairs with stage 1 tears, 11 matched pairs with stage 2 tears, and 10 matched pairs with stage 3 tears. Comparisons of the 2 cohorts revealed no differences in preoperative or postoperative motion, patient-reported outcome measures, or patient satisfaction. Furthermore, no differences were found in overall improvements in motion or outcome measures, as well as overall satisfaction.

Conclusions

Patients undergoing simultaneous RCR and BT demonstrate similar patient-reported and objective outcomes for both LR tenodesis and in-the-groove tenodesis techniques.

Arthroscopic All-Inside Biceps Tenodesis: Technique and Outcomes

The long head of the biceps tendon (LHBT) is a frequent source of disorders and pathology in the shoulder. Significant evidence is available on the management of disorders of the LHBT in the literature, and the LHBT is frequently addressed intraoperatively when involved in shoulder pathology. An all-arthroscopic, intra-articular biceps tenodesis with suture anchor fixation has several advantages that have not been well described previously, and it does not add significant morbidity to arthroscopic surgery to treat the rotator cuff or other sources of pain. Intra-articular LHBT tenodesis in the bicipital groove thus has advantages of less surgical time and a decreased bone footprint.

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

Objective

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

Methods

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

Results

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

Conclusion

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

Patient-determined outcomes after arthroscopic rotator cuff repair with and without biceps tenodesis utilizing the PITT technique

HYPOTHESIS AND BACKGROUND

The percutaneous intra-articular transtendon technique (PITT) is a simple, rapid, and low-cost method of performing a biceps tenodesis. Few studies exist that examine the patient-determined outcomes of this technique in general or in patients undergoing arthroscopic rotator cuff repair (RCR) with and without biceps tenodesis. We hypothesized that patients undergoing an isolated arthroscopic RCR would have equivalent outcomes to those undergoing RCRs with PITT biceps tenodesis.

METHODS

We compared preoperative, patient-determined outcomes scores on patients undergoing primary arthroscopic RCR with and without a PITT biceps tenodesis with postoperative scores at a minimum of 2 years. These scores included the Western Ontario Rotator Cuff score (WORC), American Shoulder and Elbow Surgeons score (ASES), Single Assessment Numeric Evaluation (SANE), Simple Shoulder Test (SST), and Shoulder Activity Level (SAL). Indication for a concomitant biceps tenodesis was a partial long head biceps tendon tear or biceps instability/subluxation.

RESULTS

A total of 153 patients underwent an isolated RCR and 131 patients underwent RCR with biceps tenodesis (RCRBT). Both groups had improvements in WORC, ASES, SANE, and SST (P < .0001) and deteriorations in the SAL (P ≤ .005). There was no difference in the change in outcome scores between the groups (RCRBT vs. RCR, respectively) for WORC (46 vs. 47; P = .85), ASES (46 vs. 47; P = .82), SANE (53 vs. 51; P = .35), SST (5.8 vs. 5.8; P = .93), and SAL (-0.9 vs. -1.4; P = .46). There was no difference between the groups in complications that required revision surgery (1.5% vs. 1.3%; P = .91).

CONCLUSIONS

Arthroscopic PITT RCRBT is safe and effective with equivalent patient-determined outcomes compared with patients undergoing RCR without biceps tenodesis.

All-Arthroscopic Reconstruction of Severe Chronic Acromioclavicular Joint Dislocations

PURPOSE

To report the outcomes of all-arthroscopic coracoclavicular (CC) ligament reconstruction and simultaneous diagnosis and treatment of glenohumeral pathologies in patients with symptomatic, chronic (>6 weeks), complete (Rockwood type III-V) acromioclavicular joint (ACJ) separations.

METHODS

We prospectively followed up 57 consecutive patients treated arthroscopically for chronic Rockwood type III (n = 11), type IV (n = 19), and type V (n = 27) ACJ dislocations. Previous ACJ surgery failed in 11 (19%). The mean delay between injury and surgery was 39 months (range, 6 months to 17 years). The mean age at surgery was 42 years (range, 19-71 years). After glenohumeral exploration, an arthroscopic modified Weaver-Dunn procedure with CC suture button fixation (Twinbridge) was performed. The CC reduction and tunnel position were analyzed with radiographs and computed tomography. The mean follow-up period was 36 months (range, 12-72 months).

RESULTS

Intra-articular pathology was treated arthroscopically in 27 patients (48%): 17 labral tears, 8 rotator cuff tears (3 partial and 5 complete), and 15 biceps lesions (4 SLAP lesions and 11 subluxations). At last follow-up, 7 patients (12%) experienced recurrent ACJ instability: 2 frank dislocations (1 trauma and 1 infection) and 5 ACJ subluxations. There was no significant correlation between subluxation and clinical outcome. The rate of recurrent ACJ instability was significantly higher in patients with higher-grade ACJ dislocations (P < .01) and/or previous failed surgery (P < .001). Recurrent subluxation was observed in 3 cases of lateral migration of the coracoid button with lateral tunnel placement, as well as 2 cases of anterior migration of the clavicular button with anterior tunnel placement. The Constant score increased from 67 (range, 28-89) to 85.5 (range, 66-100), and the mean Subjective Shoulder Value increased from 54% to 85% (P < .001). At last follow-up, 95% of patients (54 of 57) were satisfied.

CONCLUSIONS

All-arthroscopic treatment allows successful CC ligament reconstruction and simultaneous diagnosis and treatment of frequently associated (48%) glenohumeral lesions. Higher-grade ACJ dislocations, previous ACJ surgery, and misplacement of bone tunnels are risk factors for recurrent instability.

LEVEL OF EVIDENCE

Level IV, case series.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Increased fatigue of the biceps after tenotomy of the long head of biceps tendon

PURPOSE

The aim of this study is to evaluate the biomechanical parameters of biceps fatigue (time to claudication during elbow flexion) and strength between the shoulder where the tenotomy has been performed and the healthy arm. The hypothesis of this study was that measuring biceps fatigue may be more useful for determining functionality after tenotomy.

METHODS

52 patients from 2 hospitals were selected to undergo biomechanical tests of healthy and pathological arms, before and 12 months after surgery. The test consisted of (1) isometric measurement of maximal voluntary contraction (MVC) in elbow flexion and forearm supination (MVS) at baseline conditions. (2) Biceps fatigue test was performed by a submaximal contraction to 33% of MVC maintained at a time as well recorded to the time to claudication. (3) After claudication, measurements of the MVC and MVS were recorded. In addition, the Constant score, SSI functional scale, VAS scale and perceived symptoms were evaluated.

RESULTS

Of the 52 patients included in the study, 26 met the selection criteria. Two patients were lost to follow-up. The mean age was 55 ± 5.6 years. Popeye sign was observed in 58.3% of the cases. Two patients were not satisfied with the results. Preoperatively, MVC was 193.6 ± 55.2 N, which significantly improved after tenotomy to 252.1 ± 61.2 N, but this value was less than the healthy arms (280 ± 68 N). The fatigue time decreased from 141.9 ± 69.7 s preoperatively to 94.2 ± 29.9 s after tenotomy. There was also an improvement in the strength of the arm after the fatigue test. No differences in supination force were found. The Constant, SSI and VAS rating scales improved significantly.

CONCLUSIONS

Despite functional improvements of the long head of biceps tendon (LHBT) after tenotomy, this study demonstrates that the shoulder where the tenotomy has been performed will fatigue more quickly than it did preoperatively. Despite this, an improvement in the isometric contraction in flexion of the elbow with respect to the preoperative values. However, this improvement did not reach the flexion power of the contralateral healthy arm. No changes were observed in the supination force of the forearm.

LEVEL OF EVIDENCE

III.

Interference screw insertion angle has no effect on graft fixation strength for insertional Achilles tendon reconstruction

PURPOSE

To compare the effect of two interference screw insertion angles on the biomechanical properties of the insertional Achilles tendon (IAT) reconstruction.

METHODS

Nine matched pairs of fresh-frozen human cadaveric Achilles tendon specimens were randomized to two groups with interference screw insertion angles of 60° and 120°. The IAT reconstruction was performed by fixing the graft tendon with the interference screw. Each specimen was loaded to failure. The load at failure, stiffness, and mode of failure were documented. Differences in load at failure and stiffness were analysed.

RESULTS

There was no statistically significant difference between the 60° and 120° groups for failure load (149.137 ± 20.836 versus 155.428 ± 28.343 N, respectively, n.s.) and stiffness (14.523 ± 2.824 N/mm versus 14.727 ± 2.192 N/mm, respectively, n.s.). The most common mode of failure was the graft pulling out of the bone tunnel when the screw broke.

CONCLUSIONS

Graft fixation at two different interference screw insertion angles for IAT reconstruction exhibited equivalent biomechanical performance. When performing this procedure, surgeons may choose the interference screw insertion angle based on personal preference.

Surgical Management of Proximal Long Head Biceps Tendon Disorders

Disorders of the long head of the biceps tendon can make a significant contribution to shoulder pain and dysfunction. Historically, open biceps tenotomy or a proximal tenodesis of the tendon through a deltopectoral approach was used to manage biceps tendonitis and instability. Recent developments have added additional options. Arthroscopic techniques offer minimally invasive methods to secure the biceps in the suprapectoral region at the appropriate length. An open subpectoral tenodesis provides for simple exposure that secures the tendon just proximal to the musculotendinous junction and eliminates potentially diseased tendon and synovium from the biceps groove. Common fixation methods include the use of interference screws, suture anchors, and button devices. Future developments will likely add modified tenotomy techniques that will minimize the Popeye deformity in low-demand individuals. Simpler, but secure methods of fixation for higher demand patients will minimize the operative time required.