Functional Recovery After Rotator Cuff Repair: The Role of Biceps Surgery

Tenotomy or tenodesis versus conservation of the long head of the biceps tendon in the repair of isolated supraspinatus tears: A systematic review of the literature

BACKGROUND

Few studies have directly compared the outcomes of rotator cuff repair (RCR) with or without concomitant LHBT tenotomy or tenodesis. The aim of this literature review was to assess: (i) whether an adjuvant procedure on the LHBT at the time of RCR gives better functional results than RCR alone; and (ii) whether reoperation rates are higher after RCR alone or RCR+tenotomy or tenodesis.

METHODS

A literature search was carried out on PubMed, MEDLINE, Embase, Web of Science and the Cochrane database for papers published in English or French between 1st January, 2010, and 31st December, 2021. Included studies compared the results of RCR alone with RCR+concomitant tenotomy or tenodesis in patients with tears of the supraspinatus tendon or rotator cuff.

ARTICLES

A total of 626 articles were identified in the literature search and 168 were retained for more detailed examination. Forty-seven articles were read in their entirety and nine articles comparing RCR with or without concomitant tenotomy or tenodesis of the LHBT were retained for the analysis.

RESULTS

Nine articles comparing the results of RCR alone versus RCR+LHBT tenotomy or tenodesis were reviewed. The majority of patients were more than 50 years old and male. The rate of lesions to the LHBT in the studies included ranged from 26.8-60.2%. Eight of the nine studies compared the functional results of RCR alone versus RCR+tenotomy or tenodesis, with six reporting no significant difference, one reporting better outcomes after concomitant biceps surgery and one reporting worse outcomes after a biceps procedure.

DISCUSSION

This review did not provide a strong answer to our questions, owing to the heterogenicity of clinical evaluation and low level of evidence of the studies. However, it appears that in the absence of biceps pathology or in the presence of small lesions, the LHBT could be preserved. The rate of revision did not seem to be higher and cuff healing lower in this situation. Therefore, further randomized studies are required to identify the role of concomitant procedure of the biceps in case of small isolated supraspinatus repair.

LEVEL OF EVIDENCE

III; systematic review.

A shallow morphology of the intertubercular groove is associated with medial and bilateral but not lateral pulley lesions

PURPOSE

To investigate the influence of intertubercular groove (IG) morphology on the development of different types of biceps reflection pulley (BRP) injuries.

METHODS

A consecutive cohort of 221 patients with ventral shoulder pain and a preoperative diagnosis suspecting BRP injury, who underwent arthroscopy, was retrospectively reviewed. The presence or absence as well as type of pulley injury (medial, lateral or bilateral) was confirmed arthroscopically. The intertubercular groove was evaluated on MRIs after triplanar reconstruction of the axial plane. IG depth, width, medial wall angle (MWA), lateral wall angle (LWA) and total opening angle (TOA) were measured. IG depth and width were expressed in relation to the humeral head diameter. Measurements were performed by two clinicians independently and averaged.

RESULTS

Of 166 included patients 43 had bilateral, 65 medial and 38 lateral BRP lesions. 20 patients had intact BRPs and represented the control group. The intra-class correlation coefficient of measurements was 0.843-0.955. Patients with a medial or bilateral BRP injury had a flatter MWA (38.8° or 40.0° vs. 47.9°, p < 0.001), wider TOA (96.1° or 96.6° vs. 82.6°, p < 0.001), greater width (12.5 or 12.3 vs. 10.8 mm, p = 0.013) and shallower depth (5.5 or 5.4 vs. 6.2 mm, p < 0.001) than the control group. Conversely, the IG morphology of those with lateral BRP injuries did not differ significantly from the control group. The odds ratio for a medial or bilateral BRP injury when the TOA exceeded 95° was 6.8 (95% confidence interval 3.04-15.2).

CONCLUSION

A dysplastic type of IG morphology with a wide TOA, flat MWA, decreased depth and increased width is associated with the presence of medial and bilateral BRP injuries. A TOA of > 95° increases the likelihood of a medial or bilateral BRP injury 6.8-fold. Lateral BRP injuries are not associated with dysplastic IG morphology. Concomitant LHBT surgery may, therefore, not always be necessary during isolated supraspinatus tendon repair.

LEVEL OF EVIDENCE

Level III.

Biceps tenodesis combined with rotator cuff repair increases functional status and elbow strength

PURPOSE

The aim of the present study was to prospectively evaluate the elbow flexion and supination strengths and the functional outcomes of patients following arthroscopic rotator cuff repair combined with simultaneous biceps tenodesis.

METHODS

19 patients who underwent arthroscopic rotator cuff repair and biceps tenodesis with at least 24 months of follow-up were included. Patients were evaluated using a visual analog scale (VAS) for bicipital groove pain, American Shoulder and Elbow Surgeons (ASES), and constant scores (CS), biceps apex distance (BAD), elbow flexion, and supination strengths.

RESULTS

The VAS for biceps groove measurement averages in the postoperative 6th, 12th, and 24th months was lower in comparison to preoperative data and was considered to be statistically significant (p < .05). The constant score, an average of all postoperative measurements and scores, was found to be higher than preoperative values and was considered to be statistically significant (p < .01). There was a significant difference in the operated and non-operated forearm supination and elbow flexion muscle strength measurements at the postoperative 3- and 6-month follow-ups (p < .01).

CONCLUSION

Arthroscopic biceps tenodesis into the anchors of the lateral row in combination with rotator cuff repair provides an increase in the strength of elbow flexion and forearm supination, while decreasing pain.

LEVEL OF EVIDENCE

Level IV.

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.

The Effects of a Standard Postoperative Rehabilitation Protocol for Arthroscopic Rotator Cuff Repair on Pain, Function, and Health Perception

Purpose  There is still conflicting evidence to support postoperative rehabilitation protocols using immobilization following rotator cuff repair over early motion. The objective of the study was to evaluate the evolution of pain, shoulder function, and patients' perception of their health status up to 1 year after cuff rotator repair and a standard postoperative rehabilitation protocol consisting of 4 weeks of immobilization followed by a 2-week assisted controlled rehabilitation.

Methods  Descriptive, longitudinal, uncontrolled case-series study was performed on 49 patients who underwent arthroscopic rotator cuff repair following traumatic or degenerative lesions. VAS scale for pain, Constant–Murley score for function, and SF-12 score for quality of life were used as outcome measures and were administered before the rehabilitation treatment, at the end of the 2-week rehabilitation, 3 months, and 1 year after surgery.

Results  VAS pain score decreased significantly along the follow-up reaching almost a nil value after 1 year (0.2). Function as measured by Constant–Murley score had a significant improvement during follow-up, reaching a mean value of 84.6. The short form (SF)-12 score increased over time reaching 46.3 for the physical and 43.8 for the psychological dimension, respectively, at 1 year.

Conclusion  The present study confirmed an excellent outcome at 1 year after rotator cuff repair using a traditional 4-week immobilization followed by a 2-week rehabilitation protocol without evidence of tendon un-healing or re-tearing.

Level of Evidence  This is a level IV, therapeutic case series.