The long head of the biceps tendon has minimal effect on in vivo glenohumeral kinematics: a biplane fluoroscopy study

Functional Anatomy and Biomechanics of Shoulder Instability

The glenohumeral joint is the least congruent and least constrained joint with a complex relationship of static and dynamic stabilizers to balance its native mobility with functional stability. In the young athlete, anterior shoulder instability is multifactorial and can be a challenge to treat, requiring a patient-specific treatment approach. Surgical decision-making must consider patient-specific factors such as age, sport activity and level, underlying ligamentous laxity, and goals for return to activity, in addition to careful scrutiny of the underlying pathology to include humeral and glenoid bone loss and surrounding scapular bone morphology.

Long head of the biceps tendon plays a role in stress absorption and humeral head restriction during the late cocking and deceleration phases of overhead throwing: a finite element study

BACKGROUND

Emerging evidence suggests that the long head of the biceps (LHBT) may play a role in stabilizing the glenohumeral joint, and this has led to controversy around the efficacy of biceps tenotomy for superior labral anterior and posterior (SLAP) lesions. Therefore, the aim of this finite element analysis (FEA) study was to determine the stress absorption and humeral head translation restriction effects of the LHBT within the glenohumeral joint during the late cocking and deceleration phases of overhead throwing with a view to resolving the controversy around tenotomy.

METHODS

Eight FEA models were created using computed tomography and magnetic resonance imaging data from normal glenohumeral joints. The models represented 4 LHBT conditions: uninjured, subpectoral tenodesis, tenotomy, and type II SLAP lesions. The late cocking and deceleration phases of the overhead throwing were simulated for each model. The impacts of the 4 LHBT conditions on glenohumeral joint stress absorption and humeral head displacement restriction were studied based on 1) stress and related distributions on the cartilage, labrum, capsule, and LHBT; and 2) humeral head translation variation.

RESULTS

The FEA analysis showed that the magnitude of the contact stress on the articular cartilage, labrum, and capsule was the lowest in the uninjured models, followed by the subpectoral tenodesis, tenotomy, and type II SLAP lesion models. Humeral head translation was the most restricted in the subpectoral tenodesis models, followed by the tenotomy and type II SLAP lesion models.

CONCLUSION

FEA demonstrated that the LHBT plays a significant role in stress absorption and displacement restriction in the late cocking and deceleration phases of overhead throwing. Subpectoral tenodesis of the LHBT exhibited lesser amount of stress and humeral head translation than those of tenotomy, thereby making it a better option for patients who engage in overhead throwing.

Factors associated with long head of the biceps tendon tear severity and predictive insights for grade II tears in rotator cuff surgery

BACKGROUND

In rotator cuff repair, the long head of the biceps tendon (LHB) is commonly used as graft material. However, factors influencing LHB tear severity are poorly understood, and predicting grade II LHB tears is challenging. This study aimed to identify these factors preoperatively.

METHODS

The demographics, medical parameters, and pain severity of 750 patients who underwent arthroscopic surgery from January 2010 to February 2021 were evaluated to determine the factors associated with LHB tear severity and grade II tears. Both overall and largeto-massive rotator cuff tear (RCT) cohorts underwent ordinal and binary logistic regression analyses. Predictive accuracy for grade II LHB tears was determined using the area under the receiver operating characteristic curve (AUC).

RESULTS

In the overall cohort, high-sensitivity C-reactive protein (hs-CRP) >1 mg/L (P<0.001), subscapularis tear (P<0.001), hypothyroidism (P=0.031), and the tangent sign (P=0.003) were significantly associated with LHB tear severity, and hs-CRP>1 mg/L, subscapularis tear, and Patte retraction degree were significantly associated with grade II LHB tears (P<0.001). In the large-to-massive RCT cohort, hs-CRP>1 mg/L, hypertension, and age ≥50 years (P<0.05) were significantly associated with LHB tear severity, and hs-CRP>1 mg/L (P<0.001) and hypertension (P=0.026) were significantly associated with grade II LHB tears. In both cohorts, hs-CRP >1 mg/L demonstrated good predictive accuracy for grade II LHB tears (AUCs: 0.72 and 0.70).

CONCLUSIONS

Serum hs-CRP >1 mg/L is associated with LHB tear severity and serves as a reliable predictor of grade II LHB tears, facilitating preoperative assessment of the LHB as potential graft material in arthroscopic rotator cuff repair. Level of evidence: III.

The Long Head of the Biceps Has a Stabilizing Effect on the Glenohumeral Joint in Simulated Infraspinatus or Subscapularis but Not Supraspinatus Rotator Cuff Deficiency: A Biomechanical Study

PURPOSE

To investigate the stabilizing role of the long head of the biceps (LHB) for different simulated rotator cuff (RC) tears.

METHODS

Human cadaveric specimens (n = 8) were fixed in a robotic-based experimental setup with a static loading of the RC, deltoid, and the LHB. RC tears were simulated by unloading of the corresponding muscles. A throwing motion and an anterior load-and-shift test were simulated under different RC conditions by unloading the supraspinatus (SS), subscapularis (SSc), infraspinatus (IS), and combinations (SS + SSc, SS + IS, SS + SSc + IS). The LHB was tested in 3 conditions: unloaded, loaded, and tenotomy. Translation of the humeral head and anterior forces depending on loading of the RC and the LHB was captured.

RESULTS

Loading of LHB produced no significant changes in anterior force or glenohumeral translation for the intact RC or a simulated SS tear. However, if SSc or IS were unloaded, LHB loading resulted in a significant increase of anterior force ranging from 3.9 N (P = .013, SSc unloaded) to 5.2 N (P = .001, simulated massive tear) and glenohumeral translation ranging from 2.4 mm (P = .0078, SSc unloaded) to 7.4 mm (P = .0078, simulated massive tear) compared to the unloaded LHB. Tenotomy of the LHB led to a significant increase in glenohumeral translation compared to the unloaded LHB in case of combined SS + SSc (2.6 mm, P = .0391) and simulated massive tears of all SS + SSc + IS (4.6 mm, P = .0078). Highest translation was observed in simulated massive tears between loaded LHB and tenotomy (8.1 mm, P = .0078).

CONCLUSIONS

Once SSc or IS is simulated to be torn, the LHB has a stabilizing effect for the glenohumeral joint and counteracts humeral translation. With a fully loaded RC, LHB loading has no influence.

CLINICAL RELEVANCE

With an intact RC, the condition of the LHB showed no biomechanical effect on the joint stability. Therefore, from a biomechanical point of view, the LHB could be removed from the joint when the RC is intact or reconstructable. However, since there was a positive effect even of the unloaded LHB in this study when SSc or IS is deficient, techniques with preservation of the supraglenoid LHB origin may be of benefit in such cases.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

PRE-REGISTRATION

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

Dynamic Anterior Stabilization of the Shoulder With Adjustable-Loop Device

Dynamic anterior stabilization of the shoulder is a surgical procedure based on a triple soft-tissue block. This procedure is designed to fit within a gray zone between the Bristow-Latarjet procedure and the Bankart procedure, where the patient would not need a bone graft; however, capsular reconstruction alone may be insufficient to yield reliable stabilization. This article describes dynamic anterior stabilization of the shoulder using the adjustable-loop device.

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.

Glenoid Track Width Is Smaller Under Dynamic Conditions: An In Vivo Dual-Fluoroscopy Imaging Study

BACKGROUND

The glenoid track concept has been widely used to assess the risk of instability due to bipolar bone loss. The glenoid track width was commonly used as 83% of the glenoid width to determine if a lesion was on-track or off-track. However, the value was obtained under static conditions, and it may not be able to reflect the actual mechanism of traumatic dislocation during motion.

PURPOSE

To compare the glenoid track width under dynamic and static conditions using a dual-fluoroscopic imaging system.

STUDY DESIGN

Controlled laboratory study.

METHODS

In total, 40 shoulders of 20 healthy volunteers were examined for both dynamic and static tests within a dual-fluoroscopic imaging system at 5 different arm positions: 30°, 60°, 90°, 120°, and 150° of abduction, keeping the shoulder at 90° of external rotation. The participants performed a fast horizontal arm backswing for dynamic tests while keeping their arm in maximum horizontal extension for static tests. Computed tomography scans were used to create 3-dimensional models of the humerus and scapula for 2-dimensional to 3-dimensional image registration. Magnetic resonance imaging scans were obtained to delineate the medial margin of the rotator cuff insertion. The glenoid track width was measured as the distance from the anterior rim of the glenoid to the medial margin of the rotator cuff insertion and compared between static and dynamic conditions.

RESULTS

The mean glenoid track widths at 30°, 60°, 90°, 120°, and 150° of abduction were significantly smaller under dynamic conditions (88%, 81%, 72%, 69%, and 68% of the glenoid width) than those under static conditions (101%, 92%, 84%, 78%, and 77% of the glenoid width) (all P < .001). The glenoid track width significantly decreased with the increasing abduction angles in the range of 30° to 120° under static conditions (all P < .003) and 30° to 90° under dynamic conditions (all P < .001).

CONCLUSION

A smaller dynamic-based value should be considered for the glenoid track width when distinguishing on-track/off-track lesions. Clinical evidence is needed to establish the superiority of the dynamic-based value over the static-based value as an indicator for augmentation procedures.

CLINICAL RELEVANCE

Some off-track lesions might be misclassified as on-track lesions when the original commonly used static-based value of 83% is used as the glenoid track width.

Reverse Total Shoulder Arthroplasty Alters Humerothoracic, Scapulothoracic, and Glenohumeral Motion During Weighted Scaption

BACKGROUND

Reverse total shoulder arthroplasty (rTSA) typically restores active arm elevation. Prior studies in patients with rTSA during tasks that load the arm had limitations that obscured underlying three-dimensional (3D) kinematic changes and the origins of motion restrictions. Understanding the scapulothoracic and glenohumeral contributions to loaded arm elevation will uncover where functional deficits arise and inform strategies to improve rTSA outcomes.

QUESTIONS/PURPOSES

In a cohort of patients who had undergone rTSA and a control cohort, we asked: (1) Is there a difference in maximum humerothoracic elevation when scapular plane elevation (scaption) is performed with and without a handheld weight? (2) Is maximum humerothoracic elevation related to factors like demographics, patient-reported outcome scores, isometric strength, and scapular notching (in the rTSA group only)? (3) Are there differences in underlying 3D scapulothoracic and glenohumeral motion during scaption with and without a handheld weight?

METHODS

Ten participants who underwent rTSA (six males, four females; age 73 ± 8 years) were recruited at follow-up visits if they were more than 1 year postoperative (24 ± 11 months), had a BMI less than 35 kg/m 2 (29 ± 4 kg/m 2 ), had a preoperative CT scan, and could perform pain-free scaption. Data from 10 participants with a nonpathologic shoulder, collected previously (five males, five females; age 58 ± 7 years; BMI 26 ± 3 kg/m 2 ), were a control group with the same high-resolution quantitative metrics available for comparison. Participants in both groups performed scaption with and without a 2.2-kg handheld weight while being imaged with biplane fluoroscopy. Maximum humerothoracic elevation and 3D scapulothoracic and glenohumeral kinematics across their achievable ROM were collected via dynamic imaging. In the same session the American Shoulder and Elbow Surgeons (ASES) score, the Simple Shoulder Test (SST), and isometric strength were collected. Data were compared between weighted and unweighted scaption using paired t-tests and linear mixed-effects models.

RESULTS

When compared with unweighted scaption, maximum humerothoracic elevation decreased during weighted scaption for patients who underwent rTSA (-25° ± 30°; p = 0.03) but not for the control group (-2° ± 5°; p = 0.35). In the rTSA group, maximum elevation correlated with the ASES score (r = 0.72; p = 0.02), and weighted scaption correlated with BMI (r = 0.72; p = 0.02) and the SST (r = 0.76; p = 0.01). Scapular notching was observed in three patients after rTSA (Grades 1 and 2). Four of 10 patients who underwent rTSA performed weighted scaption to less than 90° humerothoracic elevation using almost exclusively scapulothoracic motion, with little glenohumeral contribution. This manifested as changes in the estimated coefficient representing mean differences in slopes in the humerothoracic plane of elevation (-12° ± 2°; p < 0.001) and true axial rotation (-16° ± 2°; p < 0.001), scapulothoracic upward rotation (7° ± 1°; p < 0.001), and glenohumeral elevation (-12° ± 1°; p < 0.001), plane of elevation (-8° ± 3°; p = 0.002), and true axial rotation (-11° ± 2°; p < 0.001). The control group demonstrated small differences between scaption activities (< |2°|), but a 10° increase in humerothoracic and glenohumeral axial rotation (both p < 0.001).

CONCLUSION

After rTSA surgery, maximum humerothoracic elevation decreased during weighted scaption by up to 88° compared with unweighted scaption, whereas 4 of 10 patients could not achieve more than 90° of elevation. These patients exhibited appreciable changes in nearly all scapulothoracic and glenohumeral degrees of freedom, most notably a near absence of glenohumeral elevation during weighted scaption. Patients with rTSA have unique strategies to elevate their arms, often with decreased glenohumeral motion and resultant compensation in scapulothoracic motion. In contrast, the control group showed few differences when lifting a handheld weight.

CLINICAL RELEVANCE

Functional deficiency in activities that load the shoulder after rTSA surgery can affect patient independence, and they may be prevalent but not captured in clinical studies. Pre- or postoperative rehabilitation to strengthen scapular stabilizers and the deltoid should be evaluated against postoperative shoulder function. Further study is required to determine the etiology of deficient glenohumeral motion after rTSA, and the most effective surgical and/or rehabilitative strategies to restore deficient glenohumeral motion after rTSA.

A biomechanical study on the effect of long head of biceps tenotomy on supraspinatus load and humeral head position during shoulder abduction

INTRODUCTION

The purpose of this study was to determine the effect of biceps tendon tenotomy on the load of the supraspinatus tendon/muscle complex during abduction of the arm from 0° to 15°.

METHODS

Eleven fresh frozen human cadaver shoulders (6 males, 5 females, age ranged 44-88 years, mean upper extremity weight 2.96 ± 0.56 kg) were included. The specimens were sequentially mounted onto a custom-made fixture attached to a pulley system and load cell. The pulley system was used to pull the supraspinatus tendon/muscle complex along its fiber directions to abduct the arm to 15°. Abduction angles were recorded with a digital inclinometer. Two conditions were tested: (1) long head biceps tendon (LHBT) intact and in normal anatomical position; (2) LHBT cut within the bicipital groove. Qualitative visual inspection of humeral head displacement during abduction was also included. Descriptive statistics were calculated. The Shapiro-Wilk test was used to establish normal data distribution, and the paired t-test was used to compare the 2 conditions.

RESULTS

For the intact condition (LHBT intact), the mean load was 45.71 ± 21.04 N. For the biceps tenotomy test, the load measured 41.37 ± 23.43 N. These differences were not significant (P = .1480). In the tenotomy condition, the humeral head initially displaced inferior, and with initiation of abduction, the humeral head translated superior to its normal position.

CONCLUSION

The results suggest that the LHBT has no critical role with initial abduction of the arm. Furthermore, the LHBT does not appear to increase loads required for the supraspinatus muscle/tendon complex to perform the same action of abduction.

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

Background:

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

Purpose:

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

Study Design:

Cohort study; Level of evidence, 3.

Methods:

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

Results:

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

Conclusion:

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

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

Objective

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

Methods

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

Results

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

Conclusions

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

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

Background

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

Methods

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

Results

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

Conclusion

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

Supplementary Information

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

Biceps Rerouting for Semirigid Large-to-Massive Rotator Cuff Tears

PURPOSE

To compare clinical and radiographic results of arthroscopic rotator cuff repair (ARCR) with biceps rerouting (BR) and those of conventional repair for semirigid, large-to-massive rotator cuff tear.

METHODS

We prospectively collected data of 111 patients who underwent either ARCR + BR (n = 59, group 1) or only ARCR (n = 52, group 2) for semirigid, large-to-massive rotator cuff tear between January 2016 and December 2018. We comparatively analyzed both groups with respect to preoperative factors including concomitant lesions of the long head of the biceps tendon (LHBT). Univariate logistic regression analysis was performed to identify predictive variables for occurrence of retear after ARCR + BR.

RESULTS

Mean age of groups 1 and 2 were 62.8 and 63.7 years, respectively (P = .484). Mean follow-up period in groups 1 and 2 were 15.1 and 25.1 months, respectively (P = .102). Mean range of motion and functional scores improved significantly (P < .05) and comparably (P > .05) in both groups. In total, 11 (18.6%) and 25 (48.1%) patients from groups 1 and 2, respectively, showed retear of the repaired rotator cuff at final follow-up (P < .01). Of 45 group 1 patients who showed less than 50% partial tearing of the LHBT preoperatively, 6 (13.3%) experienced retear. Comparatively, of 14 patients with partial tearing involving more than 50% of the LHBT, 5 (35.7%) suffered postoperative retear. If the patients had partial tear involving more than 50% of LHBT preoperatively, the odds ratio (OR) to have retear was 4.222 (P = .037). Wider (OR, 1.445, P = .047) and thinner (OR, 0.166, P = .019) LHBT were the prognostic factors to have retear. Three (5.1%) group 1 patients showed the Popeye deformity at final follow-up.

CONCLUSIONS

ARCR + BR for semirigid, large-to-massive rotator cuff tears effectively improved clinical and structural outcomes as also shown in the conventional repairs. However, the retear rate was significantly lower in patients who underwent ARCR + BR than those treated conventionally. Partial tearing involving more than 50% of the LHBT and wide and/or thin tendon morphology were significant risk factors for postoperative occurrence of retear.

LEVEL OF EVIDENCE

Level III, retrospective therapeutic comparative trial.

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.

Anterior Cable Reconstruction of the Superior Capsule Using Semitendinosus Allograft for Large Rotator Cuff Defects Limits Superior Migration and Subacromial Contact Without Inhibiting Range of Motion: A Biomechanical Analysis

PURPOSE

To biomechanically assess translation, contact pressures, and range of motion for anterior cable reconstruction (ACR) using hamstring allograft for large to massive rotator cuff tears.

METHODS

Eight cadaveric shoulders (mean age, 68 years) were tested with a custom testing system. Range of motion (ROM), superior translation of the humeral head, and subacromial contact pressure were measured at 0°, 30°, 60°, and 90° of external rotation (ER) with 0°, 20°, and 40° of glenohumeral abduction. Three conditions were tested: intact, stage III tear (supraspinatus + anterior half of infraspinatus), and stage III tear + allograft ACR (involving 2 supraglenoid anchors for semitendinosus tendon allograft fixation. Allograft ACR included loop-around fixation using 3 side-to-side sutures and an anchor at the articular margin to restore capsular anatomy along the anterior edge of the cuff defect.

RESULTS

ACR with allograft for stage III tears showed significantly higher total ROM compared with intact at all angles (P ≤ .028). Augmentation significantly decreased superior translation for stage III tears at 0°, 30°, and 60° ER for both 0° and 20° abduction, and at 0° and 30° ER for 40° abduction (P ≤ .043). Augmentation for stage III tears significantly reduced overall subacromial contact pressure at 30° ER with 0° and 40° abduction, and at 60° ER with 0° and 20° abduction (P ≤ .016).

CONCLUSION

Anterior cable reconstruction using cord-like allograft semitendinosus tendon can biomechanically improve superior migration and subacromial contact pressure (primarily in the lower combined abduction and rotation positions), without limiting range of motion for large rotator cuff tendon defects or tears.

CLINICAL RELEVANCE

In patients with superior glenohumeral instability, using hamstring allograft for ACR may improve rotator cuff tendon defect longevity by providing basic static ligamentous support to the dynamic tendon while helping to limit superior migration, without restricting glenohumeral kinematics.

Comprehensive review of the physical exam for glenohumeral instability

Glenohumeral instability is a common pathology of the shoulder joint, especially among young athletes. Despite advancements in technology and the widespread use of diagnostic imaging, a careful history and physical examination still remain the cornerstone of diagnosing patients with shoulder instability. Due to the involvement of many static and dynamic stabilizers, proficient physical examination can be challenging. With a systematic approach to clinical evaluation, the clinician can recognize characteristic patterns of relevant signs and symptoms and make an accurate diagnosis.

The Long Head of the Biceps Bristow-Bankart Procedure for Anterior Shoulder Instability

Surgical procedures to treat anterior shoulder instability are basically split into 2 groups: those for patients with important bone loss and those for patients with no bone loss. However, there is a gray zone between these procedures in which a bone graft would not be needed but bone grafting would result in a desirable improvement in stabilizing mechanisms. We describe a technique based on the triple soft-tissue block, Bankart reconstruction, and long head of the biceps tenodesis at the anterior glenoid rim. The long head of the biceps would add an anterior restrictor by itself, as well as by tensioning the inferior part of the subscapularis.

Labral Repair Versus Biceps Tenodesis for Primary Surgical Management of Type II Superior Labrum Anterior to Posterior Tears: A Systematic Review

PURPOSE

To examine the outcomes of SLAP repair versus biceps tenodesis (BT) for the index treatment of isolated type II SLAP tears.

METHODS

A search of PubMed, MEDLINE, and EMBASE was performed in April 2018 for English-language studies that presented outcomes data on patients with isolated type II SLAP tears treated with either SLAP repair or BT at the primary surgical time point.

RESULTS

Twenty-three studies (i.e., 2 randomized control trials, 7 retrospective cohort, 3 prospective cohort, 4 case-control, and 7 case series) were included. Isolated type II SLAP tears were treated via SLAP repair in 781 patients with a mean age of 35 years (range, 22-58 years) and a mean postoperative follow-up of 35 months (range, 3-63 months). BT was performed in 100 patients with a mean age of 44 years (range, 18-64 years) and a mean postoperative follow-up of 32 months (range, 24-75 months). Similar postoperative scores were noted in both the SLAP repair and BT groups for American Shoulder and Elbow Surgeons, Constant, University of California, Los Angeles, and visual analog scale pain scores. The rate of return to sports was 20% to 95% for SLAP repair and 73% to 100% for BT. Reoperation rates for SLAP repair and BT were 2.9% to 40% and 0% to 15.3%, respectively.

CONCLUSIONS

This study suggests that SLAP repair and BT are both acceptable as index treatment for isolated type II SLAP tears. SLAP repair remains the most commonly performed index procedure; however, BT appears equally efficacious and may represent an attractive alternative.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I through IV studies.

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

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

Open Biceps Tenodesis Associated With Slightly Greater Rate of 30-Day Complications Than Arthroscopic: A Propensity-Matched Analysis

PURPOSE

To compare the early complication risk associated with open biceps tenodesis (OBT) and arthroscopic biceps tenodesis (ABT) and determine which preoperative factors may influence complication rate.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was retrospectively queried from 2008 to 2016 for all procedures with CPT codes for ABT (29828) and OBT (23430). Patients were excluded if they received concomitant rotator cuff repair or shoulder arthroplasty. Patients undergoing OBT and ABT were matched by propensity scores based on age, body mass index, operative time, proportion of smokers, and proportion of concomitant subacromial decompression, distal clavicle excision, SLAP, and debridement. The incidence of adverse events in the 30-day postoperative period was compared.

RESULTS

A total of 8,032 patients met the inclusion and exclusion criteria. Prior to propensity match, patients receiving OBT and ABT, respectively, differed with respect to age (49.4 ± 13.8 vs 51.4 ± 13.2; P < .001), body mass index (29.6 ± 6.8 vs 29.9 ± 7.0; P = .029), and operative time (91.2 ± 51.3 vs 85.3 ± 43.4; P < .001). Following propensity match, 6,330 remained in the study (3,165 ABT and 3,165 OBT). OBT had significantly greater incidence of any adverse events (1.58% vs 0.95%; P = .032) and anemia requiring transfusion (0.35% vs 0%; P = .001). Multivariate analysis suggested that OBT (relative risk [RR] = 1.7, 95% confidence interval [CI], 1.1-2.7; P = .020), old age (RR = 1.6, 95% CI, 1.0-2.5), history of dyspnea (RR = 3.8, 95% CI, 1.8-7.7; P < .001), and congestive heart failure (RR = 5.5, 95% CI, 1.3-22.7; P = .019) were associated with developing a postoperative adverse event within 30 days of surgery.

CONCLUSIONS

Both procedures were found to have a low rate of complications, although OBT had a slightly greater (1.58% vs 0.95%) rate of 30-day complications than ABT. Early complication rate should not serve as impetus to direct surgical technique as number needed to treat is high, although ABT may be considered in more high-risk individuals.

LEVEL OF EVIDENCE

Level III, retrospective comparative database study.

Comparison of changes in shoulder functions between biceps tenotomy and tenodesis in an animal model

OBJECTIVES

Tenotomy and tenodesis of the long head of biceps tendon are effective pain-relieving treatments. However, there is no consensus on the functional outcome after these surgical procedures. We hypothesized that there would be no difference in ambulation parameters after recovery from the surgery between rats that underwent tenotomy versus tenodesis procedures.

METHODS

Twenty-four New Zealand rats were used and randomly divided into three groups. Each group received one of the following surgeries: tenotomy, tenodesis, and sham operation. A video-based walking track system was applied for gait analysis at day -1, 1, 3, 5, 7, 14 and 21 for each rat. Temporal and spatial parameters were obtained, and asymmetric index was calculated for each parameter.

RESULTS

Compared to the tenotomy and sham-operated groups, the rats in the tenodesis group had shorter stance phase, longer swing time, longer step length, smaller paw length, smaller intermediary toe-spread length, smaller toe-spread length, and larger foot angle right after the tenodesis procedure. After day 14, all parameters were equivalent to those of the sham-operated group. At the end of the study, there were no functional changes found in tenotomy and tenodesis groups compared with the sham-operated group and preoperative status.

CONCLUSION

Transient functional alterations in temporal and spatial parameters are found after tenotomy and tenodesis in a rat model. The functional changes in the tenodesis group existed for a longer period than in tenotomy group; however, and all parameters showed no significant differences when compared with the sham group at the conclusion of the study.

Immediate physical therapy without postoperative restrictions following open subpectoral biceps tenodesis: low failure rates and improved outcomes at a minimum 2-year follow-up

HYPOTHESIS

We aimed to determine patient-reported outcomes in patients undergoing open subpectoral biceps tenodesis with a dual-fixation construct who had no postoperative range-of-motion or weight-bearing restrictions. Our hypothesis was that patients without postoperative restrictions would have low failure rates with improved patient-reported outcomes. We further hypothesized that this technique would allow an earlier return to activity and similar functional outcomes when compared with those reported in the literature.

METHODS

In this institutional review board-approved retrospective outcome study, we evaluated 105 patients who underwent primary open subpectoral biceps tenodesis with a bicortical suture button and interference screw construct without postoperative restrictions. The primary outcome measure was failure of the biceps tenodesis. Postoperative outcome scores included the Short Form 12 (SF-12) Physical Component Score; SF-12 Mental Component Score; American Shoulder and Elbow Surgeons total score and subscales; and Disabilities of the Arm, Shoulder and Hand score.

RESULTS

A total of 98 patients (85%) were available for final follow-up at an average of 3.5 years. There were 2 failures (2.2%), at 5 weeks and 9 weeks postoperatively. Four patients underwent additional surgery unrelated to the previous tenodesis procedure. Final outcome scores indicated high levels of function, including the SF-12 Physical Component Score (mean, 51.5; SD, 7.8), SF-12 Mental Component Score (mean, 54.7; SD, 6.7), American Shoulder and Elbow Surgeons total score (mean, 89.4; SD, 14.2), and Disabilities of the Arm, Shoulder and Hand score (mean, 11.3; SD, 13.4).

CONCLUSION

Open subpectoral biceps tenodesis using a dual-fixation construct with no postoperative motion restrictions resulted in excellent outcomes with a low incidence of failure.

Popeye sign: Frequency and functional impact

INTRODUCTION

There is currently no consensus on the choice between tenotomy and tenodesis of the long head of the biceps tendon in rotator cuff repair. The Popeye sign is often seen as a drawback of tenotomy. The main objective of the present study was to determine the frequency and clinical impact of the Popeye sign.

HYPOTHESIS

The Popeye sign is rarely found clinically, and shows little functional impact following tenotomy.

MATERIALS AND METHODS

A single-center non-randomized prospective study was conducted between February and October 2015 in all patients undergoing rotator cuff surgery. Patients without surgery on the long head of the biceps tendon were excluded. The rate of Popeye sign was assessed 6 months postoperatively. Tenotomy patients with and without Popeye sign were compared in terms of pain on visual analog scale≤3, gain in range of motion, improvement in subjective shoulder value, discomfort or cramps and gain in Constant score.

RESULTS

Seven of the 55 patients included (15.2%) showed postoperative Popeye sign. There were no differences between the groups with and without Popeye sign on any of the assessment criteria except for a significantly greater improvement in mean Constant range of motion score in the Popeye group: gain of 13.8 versus 3.8 points; p=0.01.

DISCUSSION

The Popeye sign was relatively rarely observed. Functional impact in the present study was slight. Longhead of the biceps tenotomy is a justifiable treatment option in case of associated rotator cuff tear repair.

LEVEL OF EVIDENCE

IV, prospective non-randomized.

MRI vs CT-based 2D-3D auto-registration accuracy for quantifying shoulder motion using biplane video-radiography

Biplane 2D-3D registration approaches have been used for measuring 3D, in vivo glenohumeral (GH) joint kinematics. Computed tomography (CT) has become the gold standard for reconstructing 3D bone models, as it provides high geometric accuracy and similar tissue contrast to video-radiography. Alternatively, magnetic resonance imaging (MRI) would not expose subjects to radiation and provides the ability to add cartilage and other soft tissues to the models. However, the accuracy of MRI-based 2D-3D registration for quantifying glenohumeral kinematics is unknown. We developed an automatic 2D-3D registration program that works with both CT- and MRI-based image volumes for quantifying joint motions. The purpose of this study was to use the proposed 2D-3D auto-registration algorithm to describe the humerus and scapula tracking accuracy of CT- and MRI-based registration relative to radiostereometric analysis (RSA) during dynamic biplanar video-radiography. The GH kinematic accuracy (RMS error) was 0.6-1.0 mm and 0.6-2.2° for the CT-based registration and 1.4-2.2 mm and 1.2-2.6° for MRI-based registration. Higher kinematic accuracy of CT-based registration was expected as MRI provides lower spatial resolution and bone contrast as compared to CT and suffers from spatial distortions. However, the MRI-based registration is within an acceptable accuracy for many clinical research questions.

Anterior Cable Reconstruction Using the Proximal Biceps Tendon for Large Rotator Cuff Defects Limits Superior Migration and Subacromial Contact Without Inhibiting Range of Motion: A Biomechanical Analysis

PURPOSE

To assess an anterior cable reconstruction (ACR) using autologous proximal biceps tendon for large to massive rotator cuff tears.

METHODS

Nine cadaveric shoulders (mean age, 58 years) were tested with a custom testing system. Range of motion, superior translation of the humeral head, and subacromial contact pressure were measured at 0°, 30°, 60°, and 90° of external rotation (ER) with 0°, 20°, and 40° of glenohumeral abduction. Five conditions were tested: intact, stage II tear (supraspinatus), stage II tear + ACR, stage III tear (supraspinatus + anterior half of infraspinatus), and stage III tear + ACR. ACR involved a biceps tendon tenotomy at the transverse humeral ligament, preserving its labral attachment. ACR included nonpenetrating suture-loop fixation using 2 side-to-side sutures and an anchor at the articular margin to restore anatomy and secure the tendon along the anterior edge of the cuff defect. ACR was performed in 20° glenohumeral abduction and 60° ER.

RESULTS

ACR for both stage II and stage III showed significantly higher total range of motion compared with intact at all angles (P ≤ .001). ACR significantly decreased superior translation for stage II tears at 0°, 30°, and 60° ER for both 0° and 20° abduction (P ≤ .01) and for stage III tears at 0° and 30° ER for both 0° and 20° abduction (P ≤ .004). ACR for stage III tear significantly reduced peak subacromial contact pressure at 30° and 60° ER with 0° and 40° abduction and at 30° ER with 20° abduction (P ≤ .041).

CONCLUSIONS

ACR using autologous biceps tendon biomechanically normalized superior migration and subacromial contact pressure, without limiting range of motion.

CLINICAL RELEVANCE

ACR may improve rotator cuff tendon repair longevity by providing basic static ligamentous support to the dynamic tendon while helping to limit superior migration without restricting glenohumeral kinematics.

An interpolation technique to enable accurate three-dimensional joint kinematic analyses using asynchronous biplane fluoroscopy

Biplane 2D-3D model-based registration and radiostereometric analysis (RSA) approaches have been commonly used for measuring three-dimensional, in vivo joint kinematics. However, in clinical biplane systems, the x-ray images are acquired asynchronously, which introduces registration errors. The present study introduces an interpolation technique to reduce image registration error by generating synchronous fluoroscopy image estimates. A phantom study and cadaveric shoulder study were used to evaluate the level of improvement in image registration that could be obtained as a result of using our interpolation technique. Our phantom study results show that the interpolated bead tracking technique was in better agreement with the true bead positions than when asynchronous images were used alone. The overall RMS error of glenohumeral kinematics for interpolated biplane registration was reduced by 1.27 mm, 0.40 mm, and 0.47 mm in anterior-posterior, superior-inferior, and medial-lateral translation, respectively; and 0.47°, 0.67°, and 0.19° in ab-adduction, internal-external rotation and flexion-extension, respectively, compared to asynchronous registration. The interpolated biplane registration results were consistent with previously reported studies using custom synchronous biplane fluoroscopy technology. This approach will be particularly useful for improving the kinematic accuracy of high velocity activities when using clinical biplane fluoroscopes or two independent c-arms, which are available at a number of institutions.

Pediatric and adolescent anterior shoulder instability: clinical management of first-time dislocators

PURPOSE OF REVIEW

The purpose of this review is to discuss the epidemiology, pathoanatomy, diagnosis, and clinical management of pediatric and adolescent patients following a first-time shoulder dislocation.

RECENT FINDINGS

Shoulder instability is becoming increasingly common as pediatric and adolescent patients engage in earlier organized sports competition. Recommended treatment following a first-time glenohumeral dislocation event in adolescents depends on several factors, but surgical stabilization is becoming more frequently performed. Surgical indications include bony Bankart lesion, ALPSA lesion, bipolar injury (e.g. Hill-Sachs humeral head depression fracture) or off-season injury in an overhead or throwing athlete. Complications following surgical treatment are rare but most commonly are associated with recurrent instability. Young children (eg. open proximal humerus growth plate), individuals averse to surgery, or in-season athletes who accept the risk of redislocation may complete an accelerated rehabilitation program for expedited return to play in the absence of the structural abnormalities listed above.

SUMMARY

Following a first-time dislocation event in pediatric and adolescent patients, a detailed discussion of the risks and benefits of nonoperative versus operative management is critical to match the recommended treatment with the patient's injury pattern, risk factors, and activity goals.

Open subpectoral biceps tenodesis in patients over 65 does not result in an increased rate of complications

Background

Long head biceps tendon pathology is a common cause of anterior shoulder pain and is often associated with other shoulder conditions, such as rotator cuff tears and osteoarthritis. It is well accepted that older patients are at increased risk for major and minor peri- and postoperative complications.

The purpose of this study is to investigate patients over 65 years old who underwent subpectoral biceps tenodesis and compare the complication rates of this group to those of patients younger than 65 years old. The hypothesis is, that there would be no difference in complication rates and that clinical outcome scores for patients over 65 were satisfying and showed improvements over time.

Methods

There were 337 patients who underwent open subpectoral biceps tenodesis, between January 2005 and June 2015, 23 were identified as being over the age of 65 with a minimum follow up of 12 months. All patients over the age of 65 were evaluated pre- and postoperatively using Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons (ASES), Constant-Murley (CM) and Single Assessment Numeric Evaluation (SANE). Intraoperative and postoperative adverse events (fracture, infection, wound opening, rupture/failure and neurovascular injuries) related to the tenodesis procedure and to the surgery itself were collected from all 337 patients in a routine postoperative follow-up.

Results

The under 65 group (range 27–64 years) at an average follow up (FU) of 30 months (range 12–91 months) showed a 5.4% (17 out of 314) post-operative complication rate related to the subpectoral tenodesis, whereas the group over 65 (range 65–77 years) at an average follow up of 33 months (range 12–79 months) showed an 8.7% (2 out of 23) complication rate.

Conclusion

This study demonstrates that in patients over the age of 65, biceps tenodesis is a successful procedure when performed for biceps tendinopathy and concomitantly with other surgical procedures of the shoulder, and does not result in an increased rate of complications when compared to a group of patients under the age of 65.

Rotator Cuff-Sparing Approach for Antegrade Humeral Nailing With Biceps Tenodesis: A Technical Trick With Clinical Implications

Antegrade intramedullary nails are an established, effective method of fixation for humeral shaft fractures. One significant limitation of this technique is chronic postoperative shoulder pain, which is likely related to the standard approach that involves splitting the rotator cuff to gain access to the nail starting point. Furthermore, mounting evidence suggests that both the intra-articular portion of the biceps tendon and the extra-articular portion in the bicipital groove can scar down after trauma, causing pain and limiting shoulder range of motion. We describe an approach through the rotator interval with tenodesis of the biceps tendon and resection of the intra-articular portion. Using a rotator cuff interval instead of a rotator cuff insertion approach allows access to the optimal humeral nail starting point while avoiding damage to intra-articular structures of the shoulder, potentially decreasing sources of postoperative shoulder pain.

The effect of long and short head biceps loading on glenohumeral joint rotational range of motion and humeral head position

PURPOSE

To evaluate the effect of loading the long and short heads of the biceps on glenohumeral range of motion and humeral head position.

METHODS

Eight cadaveric shoulders were tested in 60° abduction in the scapula and coronal plane. Muscle loading was applied based on cross-sectional area ratios. The short and long head of the biceps were loaded individually followed by combined loading. Range of motion was measured with 2.2 Nm torque, and the humeral head apex position was measured using a MicroScribe. A paired t test with Bonferroni correction was used for statistics.

RESULTS

Long head loading decreased internal rotation in both the scapular (17.9 %) and coronal planes (5.7 %) and external rotation in the scapular plane (2.6 %) (P < 0.04). With only short head loading, maximum internal rotation was significantly increased in the scapular and coronal plane. Long head and short head loading shifted the humeral head apex posteriorly in maximum internal rotation in both planes with the long head shift being significantly greater than the short head. Long head loading also shifted the humeral apex inferiorly in internal rotation and inferiorly posteriorly in neutral rotation in the scapular plane. With the long head unloaded, there was a significant superior shift with short head loading in both planes.

CONCLUSION

Loading the long head of the biceps had a much greater effect on glenohumeral range of motion and humeral head shift than the short head of the biceps; however, in the absence of long head loading, with the short head loaded, maximum internal rotation increases and the humeral head shifts superiorly, which may contribute to impingement following tenodesis of the long head of the biceps. These small changes in rotational range of motion and humeral head position with biceps tenodesis may not lead to pathologic conditions in low-demand patients; however, in throwers, biceps tenodesis may lead to increased contact pressures in late-cocking and deceleration that will likely translate to decreased performance therefore every effort should be made to preserve the biceps-labral complex.

Normative rearfoot motion during barefoot and shod walking using biplane fluoroscopy

PURPOSE

The ankle rearfoot complex consists of the ankle and subtalar joints. This is an observational study on two test conditions of the rearfoot complex. Using high-speed biplane fluoroscopy, we present a method to measure rearfoot kinematics during normal gait and compare rearfoot kinematics between barefoot and shod gait.

METHODS

Six male subjects completed a walking trial while biplane fluoroscopy images were acquired during stance phase. Bone models of the calcaneus and tibia were reconstructed from computed tomography images and aligned with the biplane fluoroscopy images. An optimization algorithm was used to determine the three-dimensional position of the bones and calculate rearfoot kinematics.

RESULTS

Peak plantarflexion was higher (barefoot: 9.1°; 95% CI 5.2:13.0; shod: 5.7°; 95% CI 3.6:7.8; p = 0.015) and neutral plantar/dorsiflexion occurred later in the stance phase (barefoot: 31.1%; 95% CI 23.6:38.6; shod: 17.7%; 95% CI 14.4:21.0; p = 0.019) during barefoot walking compared to shod walking. An eversion peak of 8.7° (95% CI 1.9:15.5) occurred at 27.8% (95% CI 18.4:37.2) of stance during barefoot walking, while during shod walking a brief inversion to 1.2° (95% CI -2.1:4.5; p = 0.021) occurred earlier (11.5% of stance; 95% CI 0.2:22.8; p = 0.008) during stance phase. The tibia was internally rotated relative to the calcaneus throughout stance phase in both conditions (barefoot: 5.1° (95% CI -1.4:11.6); shod: 3.6° (95% CI -0.4:7.6); ns.).

CONCLUSIONS

Biplane fluoroscopy can allow for detailed quantification of dynamic in vivo ankle kinematics during barefoot and shod walking conditions. This methodology could be used in the future to study hindfoot pathology after trauma, for congenital disease and after sports injuries such as instability.

LEVEL OF EVIDENCE

II.

Alterations in Glenohumeral Kinematics in Patients With Rotator Cuff Tears Measured With Biplane Fluoroscopy

PURPOSE

To quantitatively measure the 3-dimensional (3D) glenohumeral translations during dynamic shoulder abduction in the scapular plane, using a biplane fluoroscopy system, in patients with supraspinatus rotator cuff tears.

METHODS

A custom biplane fluoroscopy system was used to measure the 3D position and orientation of the scapula and humerus of 14 patients with full-thickness supraspinatus or supraspinatus and infraspinatus rotator cuff tears and 10 controls as they performed shoulder abduction over their full range of motion. The 3D geometries of the scapula and humerus were extracted from a computed tomography scan of each shoulder. For each frame, the 3D bone position and orientation were estimated using a contour-based matching algorithm, and the 3D position of the humeral head center was determined relative to the glenoid. For each subject the superior-inferior and anterior-posterior translation curves were determined from 20° through 150° of arm elevation.

RESULTS

The humeral head in shoulders with rotator cuff tears was positioned significantly inferior compared with controls for higher elevation angles of 80° to 140° (P < .05). For both groups the humeral head translated inferiorly during shoulder abduction from 80° (P = .044; rotator cuff tear v controls: -0.2 ± 1.3 v 1.2 ± 1.4 mm) up to 140° (P = .047; rotator cuff tear v controls: -1.3 ± 2.2 v 0.44 ± 1.4 mm). There was no significant translation in the anterior- posterior direction.

CONCLUSIONS

Patients with well-compensated single or 2-tendon rotator cuff tears show no dynamic superior humeral head migration but unexpectedly show an inferior shift during active elevation. It is unclear whether the size of the translational differences found in this study, while statistically significant, are also of clinical significance.

LEVEL OF EVIDENCE

Level III, comparative study.

A Reconfigurable High-Speed Stereo-Radiography System for Sub-Millimeter Measurement of In Vivo Joint Kinematics

Relative motions within normal and pathological joints of the human body can occur on the sub-millimeter and sub-degree scale. Dynamic radiography can be used to create a rapid sequence of images from which measurements of bone motion can be extracted, but available systems have limited speed and accuracy, limit normal subject movement, and do not easily integrate into existing traditional motion capture laboratories. A high-speed stereo radiography (HSSR) system is described that addresses these limitations. The custom radiography system was placed on a standalone reconfigurable gantry structure designed to allow freedom of subject movement while integrating into an existing motion capture laboratory. Validation of the system and measurement of knee kinematics of subjects during gait confirmed the ability to record joint motion with high accuracy and high-speed.

Rotator cuff biology and biomechanics: a review of normal and pathological conditions

The glenohumeral joint is a complex anatomic structure commonly affected by injury such as tendinopathy and rotator cuff tears. This review presents an up-to-date overview of research on tendon biology and structure, shoulder joint motion and stability, tendon healing, and current and potential future repair strategies. Recent studies have provided information demonstrating the serious impact on uninjured tissues after a rotator cuff tear or other cause of altered shoulder joint mechanics. Another major focus of recent research is biological augmentation of rotator cuff repair with the goal of successfully reinstating normal tendon-to-bone structure. To effectively treat shoulder pathologies, clinicians need to understand normal tendon biology, the healing process and environment, and whole shoulder stability and function.

Feasibility of ultrasound-guided percutaneous tenotomy of the long head of the biceps tendon--A pilot cadaveric study

OBJECTIVE

To describe an ultrasound-guided proximal percutaneous tenotomy technique of long head of the biceps tendon (LHBT).

METHODS

Three fresh cadavers with no prior shoulder surgery or LHBT tears were included in the study. A single experienced musculoskeletal radiologist completed six ultrasound-guided proximal percutaneous tenotomies of LHBT. A superficial to deep approach was performed on four shoulders using an arthroscopic banana blade or retractable blade. A deep to superficial approach was performed on two shoulders using an arthroscopic hook blade. A blinded anatomist dissected each specimen and graded the tenotomy, length of proximal LHBT stump, and evidence of iatrogenic injuries.

RESULTS

Four of the six cadaveric LHBTs were fully transected. The two partially transected tenotomies were performed using the arthroscopic banana and retractable serrated blades (63% and 80% transections, respectively). The proximal LHBT stump mean length was 2.6 cm (95% CI, 1.8-3.4). There was no evidence of iatrogenic lesions.

CONCLUSIONS

This cadaveric study showed that the ultrasound-guided percutaneous tenotomy of the LHBT is a feasible procedure. The deep to superficial approach using an arthroscopic hook blade resulted in complete transection. Further cadaveric studies with larger numbers are warranted to confirm this novel technique's applicability in clinical practice.

Postoperative restoration of upper extremity motion and neuromuscular control during the overhand pitch: evaluation of tenodesis and repair for superior labral anterior-posterior tears

BACKGROUND

Superior labral anterior-posterior (SLAP) tears are a common cause of shoulder pain and dysfunction in overhand throwers. Treatment outcomes remain unpredictable, with a large percentage of athletes unable to return to sport. There is considerable debate about the optimal treatment between debridement, repair, and tenodesis.

HYPOTHESIS

Labral repair more closely restores neuromuscular control and motion during the overhand pitch than tenodesis of the long head of the biceps.

STUDY DESIGN

Controlled laboratory study.

METHODS

Eighteen pitchers, including 7 uninjured controls, 6 players pitching after SLAP repair, and 5 players pitching after subpectoral biceps tenodesis (BT), underwent simultaneous surface electromyographic measurement at 1500 Hz and motion analysis at 120 Hz with a 14-camera markerless motion analysis system and high-speed video (120 Hz) to confirm accurate motion tracking. Patients had undergone surgery at least 1 year previously and had returned to pitching with a painless shoulder.

RESULTS

No significant differences were observed in the long head of the biceps muscle, short head of the biceps muscle, deltoid, infraspinatus, or latissimus activity between controls, patients after SLAP repair, and patients after BT. The variability from pitch to pitch for each study participant was similar between groups. Based on visual inspection of the activity time plots, BT appeared to more closely restore the normal pattern of muscular activation within the long head of the biceps muscle than did SLAP repair. There were no significant differences between controls and postoperative patients in the majority of pitching kinematics; however, pitchers after SLAP repair showed significantly altered patterns of thoracic rotation (P = .034) compared with controls and were significantly less likely to fall into previously published normal values for lead knee flexion at front foot contact (P = .019).

CONCLUSION

While both BT and SLAP repair can restore physiologic neuromuscular control, pitchers who undergo SLAP repair may exhibit altered patterns of thoracic rotation when compared with controls and pitchers who undergo BT.

CLINICAL RELEVANCE

While both tenodesis and SLAP repair can restore physiologic neuromuscular control, SLAP repair may alter pitching biomechanics.

Subpectoral biceps tenodesis for the treatment of type II and IV superior labral anterior and posterior lesions

BACKGROUND

Surgical repair remains the gold standard for most type II and type IV superior labral anterior and posterior (SLAP) lesions that fail nonoperative management. However, most recently, there have been data demonstrating unacceptably high failure rates with primary repair of type II SLAP lesions. Biceps tenodesis may offer an acceptable, if not better, alternative to primary repair of SLAP lesions.

HYPOTHESIS

Subpectoral biceps tenodesis provides satisfactory, reproducible outcomes for the treatment of type II and type IV SLAP lesions.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Patients who underwent subpectoral biceps tenodesis and labral debridement for type II and type IV SLAP lesions by a single board-certified shoulder surgeon from 2006 to 2012 were evaluated. Exclusion criteria included those patients who underwent biceps tenodesis with an associated rotator cuff repair, anterior labral repair, or posterior labral repair. Outcome measures included the visual analog scale (VAS) for pain, the American Shoulder and Elbow Surgeons (ASES) score, and demographic data.

RESULTS

Between 2006 and 2012, a total of 36 subpectoral biceps tenodesis procedures were performed in 33 patients for type II or IV SLAP lesions. Twenty-six patients with 29 shoulder surgeries were available for follow-up. The average age was 46.7 years, with 16 male and 10 female patients participating in the study. The average follow-up was 40.17 months. There was a significant improvement in ASES and VAS scores: 48.1 and 6.4 preoperatively compared with 87.5 and 1.5 postoperatively, respectively (P < .001). There was no significant difference based on SLAP lesion type, patient age, or patient sex. Of 29 shoulders, 26 (89.66%) were able to return to the previous level of activity.

CONCLUSION

This study adds to the evolving literature supporting biceps tenodesis as a viable treatment for type II and IV SLAP lesions. Patient age had no effect on the outcomes. Based on these results, biceps tenodesis is a safe, effective, and technically straightforward alternative to primary SLAP repair in patients with type II and IV SLAP tears.

Coracohumeral Distances and Correlation to Arm Rotation: An In Vivo 3-Dimensional Biplane Fluoroscopy Study

Background:

Reduced coracohumeral distances have been reported to be associated with anterior shoulder disorders such as subscapularis tears, biceps tendon injuries, and leading edge supraspinatus tears.

Purpose:

To determine the variability in coracohumeral distance as a function of arm rotation in healthy male subjects. The null hypothesis was that no differences in coracohumeral distance would exist with respect to arm rotation.

Study Design:

Descriptive laboratory study.

Methods:

A total of 9 male participants who had full range of motion, strength, and no prior surgery or symptoms in their tested shoulders were enrolled in this institutional review board–approved study. Computed tomography scans of the shoulder were obtained for each subject. A dynamic biplane fluoroscopy system recorded internal and external shoulder rotation with the arm held in the neutral position. Three-dimensional reconstructions of each motion were generated, and the coracohumeral distance and coracoid index (lateral extension of the coracoid) were measured.

Results:

The mean coracohumeral distance in neutral rotation was 12.7 ± 2.1 mm. A significantly shorter minimum coracohumeral distance of 10.6 ± 1.8 mm was achieved (P = .001) at a mean glenohumeral joint internal rotation angle of 36.6° ± 19.2°. This corresponded to a reduction in coracohumeral distance of 16.4% (range, 6.6%-29.8%). The mean coracoid index was 14.2 ± 6.8 mm. A moderate correlation (R = −0.75) existed between the coracohumeral distance and coracoid index.

Conclusion:

Coracohumeral distance was reduced during internal rotation. Decreased coracohumeral distance was correlated with larger coracoid indices.

Clinical Relevance:

This study provides a reference value for coracohumeral distance in the healthy male population. Knowledge of how coracohumeral distance varies over the range of arm internal-external rotation may improve the clinical diagnosis and treatment plan for patients with anterior shoulder pathology, specifically subcoracoid impingement. Imaging of the coracohumeral distance during internal rotation with the hand at approximately midline should be considered to assess patients with anterior shoulder pain.

The effect of biceps adhesions on glenohumeral range of motion: a cadaveric study

BACKGROUND

Previous studies have demonstrated that the humerus slides along the long head of the biceps tendon (LHBT). Blocking this motion may result in decreased glenohumeral (GH) range of motion (ROM). The goal of the study was to characterize the excursion of the LHBT and measure the effect of biceps adhesions on GH ROM.

MATERIALS AND METHODS

A custom biomechanical testing setup was used to measure the excursion of the LHBT and rotation of the humerus at 0°, 15°, 30°, 60°, and 90° of GH abduction in the scapular plane. An in situ biceps tenodesis with the biceps anchor still intact, thus simulating biceps adhesions, was sequentially performed in 2 positions: 0° abduction and maximum external rotation, followed by 0° abduction and maximum internal rotation. The effect of tenodesis on ROM was measured.

RESULTS

There was an average excursion of 19.4 ± 5.4 mm of the LHBT as the humerus was taken through ROM in the scapular plane. Tenodesis in 0° abduction and maximum internal rotation resulted in a significant decrease in GH external rotation of 47.3° ± 12.2° (P = .007) with the arm in 0° abduction.

CONCLUSIONS

Tenodesis in maximum internal rotation limited rotation significantly, such that in situ tenodesis without proximal tenotomy should not be performed. Furthermore, in situations where the biceps is at risk for scarring, such as proximal humeral fractures, shoulder arthroplasty, and the stiff shoulder, the biomechanical consequence of biceps adhesions may be similar to in situ tenodesis and may limit ROM and clinical outcomes.

Effect of plane of arm elevation on glenohumeral kinematics: a normative biplane fluoroscopy study

BACKGROUND

Understanding glenohumeral motion in normal and pathologic states requires the precise measurement of shoulder kinematics. The effect of the plane of arm elevation on glenohumeral translations and rotations remains largely unknown. The purpose of this study was to measure the three-dimensional glenohumeral translations and rotations during arm elevation in healthy subjects.

METHODS

Eight male subjects performed scaption and forward flexion, and five subjects (three men and two women) performed abduction, inside a dynamic biplane fluoroscopy system. Bone geometries were extracted from computed tomography images and used to determine the three-dimensional position and orientation of the humerus and scapula in individual frames. Descriptive statistics were determined for glenohumeral joint rotations and translations, and linear regressions were performed to calculate the scapulohumeral rhythm ratio.

RESULTS

The scapulohumeral rhythm ratio was 2.0 ± 0.4:1 for abduction, 1.6 ± 0.5:1 for scaption, and 1.1 ± 0.3:1 for forward flexion, with the ratio for forward flexion being significantly lower than that for abduction (p = 0.002). Humeral head excursion was largest in abduction (5.1 ± 1.1 mm) and smallest in scaption (2.4 ± 0.6 mm) (p < 0.001). The direction of translation, as determined by the linear regression slope, was more inferior during abduction (-2.1 ± 1.8 mm/90°) compared with forward flexion (0.1 ± 10.9 mm/90°) (p = 0.024).

CONCLUSIONS

Scapulohumeral rhythm significantly decreased as the plane of arm elevation moved in an anterior arc from abduction to forward flexion. The amount of physiologic glenohumeral excursion varied significantly with the plane of elevation, was smallest for scaption, and showed inconsistent patterns across subjects with the exception of consistent inferior translation during abduction.