Arthroscopic suprapectoral and open subpectoral biceps tenodesis: a comparison of minimum 2-year clinical outcomes

Arthroscopic Suprapectoral Retensioning Biceps Tenodesis

Tendinopathy of the long head of biceps is a relatively common pathology that we usually see in most of our shoulder arthroscopy procedures. Surgical treatment for long head of biceps tendinopathies ranges from simple biceps tenotomy to biceps tenodesis depending on many factors, two of which are the age and the patient's level of activity. Various techniques in the literature for biceps tenodesis have been described, such as whether to do it open or arthroscopically, suprapectoral or subpectoral, as well as the type of fixation to be used. However, the optimal option is still debatable. In this Technical Note, we describe an arthroscopic technique for distal suprapectoral biceps tenodesis using a knotless corkscrew anchor that has many advantages, such as being an all-arthroscopic with the ability to retension the tendon after implantation. We support our technique with photos and videos with detailed explanations of the technique.

Arthroscopic suprapectoral biceps tenodesis provided earlier shoulder function restoration compared with open subpectoral biceps tenodesis during the recovery phase

BACKGROUND

This study compared the clinical outcomes of open subpectoral biceps tenodesis and arthroscopic suprapectoral biceps tenodesis for symptomatic biceps tenosynovitis. Although both techniques have pros and cons, no studies have compared clinical and functional outcomes during the recovery phase. Previous studies show that suprapectoral tenodesis has a higher probability of Popeye deformity and postoperative bicipital pain and stiffness, whereas subpectoral tenodesis has a higher risk of nerve complications and wound infections. This study aimed for clinical comparison between arthroscopic suprapectoral biceps tenodesis and open subpectoral biceps tenodesis.

METHODS

This study is a retrospective review of institutional records of patients with biceps tendinitis who underwent open or arthroscopic biceps tenodesis. Surgical indications included biceps tenosynovitis, biceps partial tear, and biceps pulley lesion. Patients with prior shoulder surgery, preoperative shoulder stiffness, or full-thickness tear of rotator cuff were excluded. Tenodesis was considered when the pain recurs within 3 months despite conservative treatment including at least 2 triamcinolone injections on the biceps tendon sheath. Visual analog scale (VAS) score for pain, presence of the night pain, American Shoulder and Elbow Surgeons (ASES) score, Constant score, and range of motion were assessed preoperatively at 3, 6, 12, and 24 months postoperatively and the last follow-up.

RESULTS

A total of 72 patients (33 with arthroscopic suprapectoral biceps tenodeses and 39 with open subpectoral biceps tenodeses) were included in analysis. At postoperative 6 months, lower VAS score (0.4 ± 0.8 vs. 1.7 ± 1.9, P < .001), and the presence of the night pain (2 [6%] vs. 14 [36%], P = .002), ASES score (89.6 ± 9.2 vs. 81.4 ± 14.6, P = .006), and Constant score (89.4 ± 5.6 vs. 82.0 ± 12.5, P = .003) compared with the subpectoral group. The mean number of postoperative steroid injections for pain control in the subpectoral group (0.51 ± 0.80) was significantly higher than that in the suprapectoral group (0.18 ± 0.40) (P = .031). However, postoperative clinical outcomes were restored similar between the 2 groups at 12 months and the last follow-up.

DISCUSSION

Arthroscopic suprapectoral biceps tenodesis performed statistically better than the subpectoral biceps tenodesis for the VAS, ASES, night pain, and Constant score at postoperative 6 months. However, only night pain and the Constant score showed differences that exceeded minimum clinically important difference during the recovery phase. At postoperative 12 and 24 months, biceps tenodesis provided satisfactory clinical outcomes and pain relief regardless of the fixation technique and suture anchor location.

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".

An Expedited Sling Immobilization Protocol After Isolated Biceps Tenodesis Results in Clinical and Patient-Reported Postoperative Outcomes Equivalent to a Standard Rehabilitation Protocol

Purpose

To characterize clinical and patient-reported outcomes for patients after isolated biceps tenodesis (BT) who underwent either standard or expedited sling immobilization protocols following surgery.

Methods

This retrospective cohort study compared patients who were assigned to use a sling for either 4 to 6 weeks (standard) or 0 to 2 weeks (expedited) following an isolated BT. Primary endpoint included rate of re-rupture, surgical revision, loss of fixation, and Popeye deformity. Secondary endpoints included shoulder range of motion (ROM) as well as pre- and postoperative patient-reported outcomes (PROs) of pain and function. Missing data were managed via multiple imputation with chained equations. Complication prevalence 95% confidence intervals were calculated using the Clopper Pearson method and a series of hierarchical mixed effects linear regressions were performed to assess differences between sling interventions in PROs and ROM.

Results

The average age of the standard cohort (n = 66) was 49 years (±14 years), and the average age of the expedited cohort (n = 69) was 47 years (±14 years). The expedited and standardized cohorts demonstrated 0.4 and 0.3 complications per 10,000 exposure days, respectively, with no significant difference between groups (1.4 [95% confidence interval 0.2-10.0], P = .727). There was no demonstrated difference in forward flexion, abduction, or external ROM. The expedited group had less improvement in visual analog scale for pain scores that was not clinically significant and there were no differences in PROs of function.

Conclusions

No statistically significant difference in the rate of re-rupture, surgical revision, loss of fixation, or Popeye deformity was noted between protocols after isolated BT. Furthermore, there were no clinically significant differences in ROM or PROs identified between protocols after isolated BT. This study suggests that patients who have undergone isolated BT may safely discontinue sling use within 2 weeks after surgery.

Level of Evidence

Level III, retrospective comparative study.

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.

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

Background

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

Methods

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

Results

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

Conclusion

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

Reproducible and Effective Biceps Tenodesis Method Utilizing In-Office Nano-Arthroscopy

Biceps tendinopathy is a common cause of chronic anterior shoulder pain characterized by altered joint mechanics with considerable deficits in range of motion secondary to pain. The benefits of in-office nano-arthroscopy (IONA) include the ability to diagnosis and treat biceps tendinopathy, quicker patient recovery, reduced cost, and improved patient satisfaction. The purpose of this technical report is to describe the technique for performing IONA for biceps tendinopathy (biceps tenotomy/biceps tenodesis), with special consideration for obtaining adequate local anesthesia, proper indications, adequate visualization, and the advantages of performing these procedures in the office rather than the operating room.

The management of the long head of the biceps in rotator cuff repair: A comparative study of high vs. subpectoral tenodesis

BACKGROUND

Tenodesis of the long head of the biceps (LHB) is commonly undertaken during arthroscopic rotator cuff repair. We assessed the clinical and structural outcomes after high arthroscopic tenodesis (HAT) or mini-open subpectoral tenodesis (ST). We hypothesized that the clinical and structural results after HAT and ST are similar.

METHODS

We included 40 patients with rotator cuff tear and LHB tendinopathy. Twenty patients (7 women and 13 men; mean age: 57.9 years; range: 56-63 years) were treated using HAT, and 20 patients (8 women and 12 men; mean age: 58.5 years; range: 55-64 years) were treated using ST. Functional evaluation was performed preoperatively and at 6 weeks, 6 months, and 1 year after surgery, using the Constant Murley Score and Simple Shoulder Test scores; the LHB was evaluated using the LHB score. A Visual Analogue Scale was administered to all patients preoperatively and 2 days after surgery.

RESULTS

The postoperative total and pain subscale's Constant scores were significantly higher in the ST group. Moreover, 2 LHB score values were significantly different between the groups. The postoperative LHB total score in the ST and HAT groups averaged 86.9 ± 4.1 (mean ± SD) points and 73.3 ± 6.4 points, respectively. The Pain/Cramps subscale in the ST and HAT groups averaged 47.1 ± 5.9 and 33.2 ± 4.6 points, respectively. The 2 groups showed no difference in Visual Analogue Scale values (5.5 in the HAT group; 5.8 in the ST group) postoperatively. One patient in the HAT group reported a secondary onset of Popeye deformity.

CONCLUSION

Both high arthroscopic and mini-open ST of the LHB tendon produced reliably good functional results, but the ST group was associated with better postoperative clinical outcomes.

A Radiostereometric Analysis of Tendon Migration After Arthroscopic and Mini-Open Biceps Tenodesis: Interference Screw Versus Single Suture Anchor Fixation

BACKGROUND

Studies suggest that similar clinical results are achieved via arthroscopic and open biceps tenodesis (BT) techniques.

PURPOSE

To quantify the postoperative migration of the BT construct between arthroscopic suprapectoral BT (ASPBT) and open subpectoral BT (OSPBT) techniques via interference screw (IS) or single-suture suture anchor (SSSA) fixation using radiostereometric analysis.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Distal migration of the biceps tendon after OSPBT with a polyetheretherketone IS, OSPBT with 1 SSSA, ASPBT with polyetheretherketone IS, and ASPBT with 2 SSSAs was measured prospectively. Patients with symptomatic biceps tendinopathy and preoperative patient-reported outcome measures (PROMs) including Constant-Murley subjective, Single Assessment Numeric Evaluation, or Patient-Reported Outcomes Measurement Information System-Upper Extremity scores were included. A tantalum bead was sutured on the proximal end of the long head of the biceps tendon before fixation of tendon tissue. Anteroposterior radiographs were performed immediately postoperatively, at 1 week, and at 3 months. Bead migration was measured, and preoperative PROMs were compared with those at latest follow-up.

RESULTS

Of 115 patients, 94 (82%) were available for final follow-up. IS fixation yielded the least tendon migration with no difference between the open and arthroscopic approaches (4.31 vs 5.04 mm; P = .70). Fixation with 1 suture anchor demonstrated significantly greater migration than that achieved with an IS at both 1 week (6.47 vs 0.1 mm, 6.47 vs 1.75 mm, P < .001;) and 3 months (14.76 vs 4.31 mm, 14.76 vs 5.04 mm, P < .001) postoperatively. Two-suture anchor fixation yielded significantly greater migration than IS fixation at 1 week (7.02 vs 0.1 mm, P < .001; 7.02 vs 1.75 mm, P = .003) but not 3 months postoperatively (8.06 vs 4.31 mm, P = .10; 8.06 vs 5.04 mm, P = .07). Four patients with suture anchor fixation (3 patients in the OSPBT 1 SSSA group, 9.4%, and 1 patient in the ASPBT 2 SSSAs group, 3.8%) developed a Popeye deformity, whereas no Popeye deformities occurred in the IS groups. Mean 3-month bead migration in patients with and without a Popeye deformity was 60.8 and 11.2 mm, respectively (P < .0001). PROMs did not differ among groups at final follow-up.

CONCLUSION

Interference screw fixation yielded the least tendon migration whether achieved arthroscopically or open. The available data indicated that fixation with 1 SSSA but not 2 SSSAs resulted in significantly greater migration than that achieved with an IS. Despite variations in tendon migration, PROMs were similar among all groups. When SSSAs are used, tendon migration may be minimized by using ≥2 anchors.

Depressive and Anxiety Disorders Increase Risk for Recurrent Anterior Shoulder Pain Following Arthroscopic Suprapectoral Biceps Tenodesis

Purpose

To evaluate factors associated with postoperative anterior shoulder pain following arthroscopic suprapectoral biceps tenodesis (ABT) and to determine the clinical impact of postoperative anterior shoulder pain.

Methods

A retrospective study of patients that underwent ABT between 2016 and 2020 was conducted. Groups were categorized by the presence (ASP+) or absence (ASP-) of postoperative anterior shoulder pain. Patient-reported outcomes (American Shoulder and Elbow score [ASES], visual analog scale [VAS] for pain, subjective shoulder value [SSV]), strength, range of motion, and complication rates were analyzed. Differences between continuous and categorical variables were tested with two-sample t-tests and chi-squared or Fisher's exact tests, respectively. Variables collected at different postoperative timepoints were analyzed using mixed models with post hoc comparisons when significant interactions were detected.

Results

A total of 461 (47 ASP+, 414 ASP-) patients were included. A statistically significant lower mean age was observed in the ASP+ group (P < .001). A statistically significant higher prevalence of major depressive disorder (MDD) (P = .03) or any anxiety disorder (P = .002) was observed in the ASP+ group. Prescription medication with psychotropic medications (P = .01) was significantly more prevalent in the ASP+ group. No significant differences were observed in the proportion of individuals reaching the minimal clinical important difference (MCID) for ASES, VAS, or SSV between groups.

Conclusions

A pre-existing diagnosis of major depressive disorder or any anxiety disorder, as well as the use of psychotropic medications was associated with postoperative anterior shoulder pain following ABT. Other factors associated with anterior shoulder pain included younger age, participation in physical therapy before surgery, and lower rate of concomitant rotator cuff repair or subacromial decompression. Although the proportion of individuals reaching MCID did not differ between groups, the presence of anterior shoulder pain after ABT resulted in prolonged recovery, inferior PROs, and a higher incidence of repeat surgical procedures. The decision to perform ABT in patients diagnosed with MDD or anxiety should be carefully considered, given the correlation to postoperative anterior shoulder pain and inferior outcomes.

Level of Evidence

Level III, retrospective case-control study.

Subpectoral, Suprapectoral, and Top-of-Groove Biceps Tenodesis Procedures Lead to Similar Good Clinical Outcomes: Comparison of Biceps Tenodesis Procedures

Purpose

To determine whether there is a difference in clinical results among open subpectoral (SB), arthroscopic low-in-groove suprapectoral (SP), and arthroscopic top-of-groove (TOG) locations in terms of patient-reported outcome measures for biceps tenodesis (BT) procedures using a global, self-reporting registry.

Methods

We identified patients who underwent BT surgery in the Surgical Outcomes System registry. The inclusion criteria were isolated primary surgical procedures for BT, excluding patients with rotator cuff and labral repairs. Additional search requirements included repair location and 100% compliance with pretreatment and 2-year follow-up surveys. This study measured clinical outcomes comparing the 3 aforementioned techniques using the American Shoulder and Elbow Surgeons (ASES) score, visual analog scale (VAS) pain score, and Single Assessment Numeric Evaluation (SANE) score before treatment and at 3 months, 6 months, 1 year, and 2 years postoperatively. In addition, postoperative VAS pain scores were collected at 2 and 6 weeks. Statistical analysis was conducted using analysis of variance (Kruskal-Wallis test) and the Wilcoxon test.

Results

A total of 1,923 patients from the Surgical Outcomes System registry qualified for the study; of these, 879 underwent the SB technique, 354 underwent the SP technique, and 690 underwent the TOG technique. There was no statistically significant difference in the demographic characteristics among the groups except that the TOG group was older: 60.76 years versus 54.56 years in the SB group and 54.90 years in the SP group (P < .001). In all groups, the ASES score statistically improved from before treatment (mean, 49.29 ± 0.63) to 2 years postoperatively (mean, 86.82 ± 0.80; P < .05). There were no statistically significant differences among the 3 groups in the VAS, ASES, and SANE scores at all time points (P > .12) except for the VAS score at 1 year (P = .032) and the ASES score at 3 months (P = .0159). At 1 year, the mean VAS score in the SB group versus the TOG group was 1.146 ± 1.27 versus 1.481 ± 1.62 (P = .032), but the minimal clinically important difference (MCID) was not met. The 3-month ASES Index scores in the SB, SP, and TOG groups were 68.991 ± 18.64, 66.499 ± 17.89, and 67.274 ± 16.9, respectively (P = .0159), and similarly, the MCID was not met. At 2 years, the ASES scores in the SB, SP, and TOG groups improved from 49.986 ± 18.68, 49.54 ± 16.86, and 49.697 ± 7.84, respectively, preoperatively to 86.00 ± 18.09, 87.60 ± 17.69, and 86.86 ± 16.36, respectively, postoperatively (P > .12).

Conclusions

The SB, SP, and TOG BT procedures each resulted in excellent clinical improvement based on patient-reported outcome measures from a global registry. On the basis of the MCID, no technique was clinically superior to the other techniques in terms of VAS, ASES, or SANE scores at any time point up to 2 years.

Level of Evidence

Level III, retrospective comparative study.

Two-Year Clinical Outcomes and Survivorship After Isolated Biceps Tenodesis

PURPOSE

The purpose of this study was to evaluate clinical outcomes and survivorship of isolated biceps tenodesis (BT) at a minimum of 2 years and to identify patient-specific factors associated with these outcomes in patients undergoing BT without concomitant rotator cuff repair (RCR). We hypothesized that patient-reported outcomes would be significantly improved on American Shoulder and Elbow Surgeons Survey (ASES) and Single Assessment Numeric Evaluation (SANE), with a high rate of survivorship (>90%) at 2-year follow-up.

METHODS

A retrospective review of an institutional registry was performed to identify patients who underwent BT from July 2016 to December 2017. Patients >18 years old who underwent an open or arthroscopic BT procedure using an interference screw, button, or anchor for underlying bicipital pathology, without a concomitant RCR or shoulder arthroplasty, and were a minimum of 2 years postoperative were included. Patients were administered ASES and SANE questionnaires preoperatively and at final follow-up. Survivorship was evaluated using Kaplan-Meier analysis. Failure was defined as any patient who underwent reoperation related to the index surgery.

RESULTS

A total of 110 patients (mean ± standard deviation age, 48.60 ± 12.14 years) who underwent isolated BT with a follow-up of 24.90 ± 3.95 months were included in analysis. There was a significant improvement in ASES and SANE at final follow-up (P < .001), with 81% to 84% of patients achieving minimal clinically important difference (MCID), 72% to 82% achieving substantial clinical benefit (SCB), and 72% to 80% achieving patient-acceptable symptom state (PASS). Worker's Compensation (WC) patients had a decreased likelihood of achieving PASS on ASES (P = .015) and SANE (P = .012). Four cases were deemed failures (3 revision BTs and 1 capsular debridement) at 15.09 ± 9.57 months. WC did not have a significant effect on likelihood of BT failure.

CONCLUSION

Biceps tenodesis provided significant clinical improvement and high rates of survivorship 2 years postoperatively. WC was associated with a decreased likelihood of achieving PASS. These results support the continued use of isolated BT for treating biceps pathology.

LEVEL OF EVIDENCE

IV, case series.

No Difference in Clinical Outcomes for Arthroscopic Suprapectoral Versus Open Subpectoral Biceps Tenodesis at Midterm Follow-up: A Randomized Prospective Analysis

BACKGROUND

We have previously reported the 1-year outcomes of arthroscopic suprapectoral biceps tenodesis (ASPBT) versus open subpectoral biceps tenodesis (OSPBT) for the management of long head of the biceps tendon (LHBT) pathology. While patients had similar 1-year biceps muscle strength and pain, longer-term functional outcomes are unknown.

PURPOSE

To directly compare clinical outcomes of ASPBT versus OSPBT with interference screw fixation, distal to the bony bicipital groove, at a minimum of 2 years' follow-up.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A total of 85 patients undergoing biceps tenodesis (BT) for LHBT disease were randomized into the ASPBT or OSPBT group. Both techniques utilized polyether ether ketone inference screws for tenodesis fixation. Patients completed American Shoulder and Elbow Surgeons (ASES), Constant subjective, and Single Assessment Numeric Evaluation (SANE) questionnaires preoperatively and again at 6 months, 12 months, and at the final follow-up at a minimum of 24 months.

RESULTS

A total of 73 patients (37/42 randomized to ASPBT [88%]; 36/42 randomized to OSPBT [86%]) with a mean age of 50.4 ± 10.3 years and a mean body mass index of 29 ± 7.9 were included in clinical outcome analyses. The mean final follow-up was 2.9 years (ASPBT, 3 years; OSPBT, 2.8 years [range 2-5.2 years]). Comparison of demographic characteristics and intraoperative findings showed no significant differences in age, sex, concomitant procedures, and rotator cuff disease. No statistically significant differences in the ASES (P = .25), Constant subjective (P = .52), and SANE scores (P = .61) were found at the final follow-up. Clinical outcomes scores showed no significant improvement from a mean of 12.6 months to the final follow-up at 34.5 months (ASPBT: ASES, P = .43; Constant, P = .25; SANE, P = .45 vs OSPBT: ASES, P = .65; Constant, P = .78; SANE, P = .70). No patients required revision of BT in either group.

CONCLUSION

This study reported a minimum of 2-year follow-up of patients undergoing ASPBT or OSPBT, utilizing the same interference screw technique, for the management of LHBT pathology in the setting of concomitant shoulder procedures. There were no significant differences in patient-reported outcomes and complication rates found at any time point.

REGISTRATION

NCT02192073 (ClinicalTrials.gov identifier).

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.

How Long Does It Take to Achieve Clinically Significant Outcomes After Isolated Biceps Tenodesis?

Background:

Clinically significant outcomes (CSOs) connect patient-reported outcome measures data to patient-perceived benefit. Although investigators have established threshold values for various CSOs, the timeline to achieve these outcomes after isolated biceps tenodesis (BT) has yet to be defined.

Purpose:

To define the time-dependent nature of minimal clinically important difference (MCID), substantial clinical benefit (SCB), and Patient Acceptable Symptom State (PASS) achievement after isolated BT.

Study Design:

Case series; Level of evidence, 4.

Methods:

The American Shoulder and Elbow Surgeons score (ASES), the Single Assessment Numeric Evaluation, and the Constant-Murley score (CMS) were administered preoperatively and at 6 and 12 months postoperatively to patients undergoing isolated BT between 2014 and 2018 at our institution. Cumulative probabilities for achieving MCID, SCB, and PASS were calculated using Kaplan-Meier survival analysis. Weibull parametric regression evaluated the hazard ratios (HRs) of achieving earlier MCID, SCB, and PASS.

Results:

Overall cohort (N = 190) achievement rates ranged between 77.8% and 83.2% for MCID, between 42.2% and 80.2% for SCB, and between 59.7% and 62.9% for PASS. Median achievement time was 5.3 to 6.1 months for MCID, 5.9 to 6.4 months for SCB, and 6.07 to 6.1 months for PASS. Multivariate Weibull parametric regression identified older age, male sex, higher body mass index, preoperative thyroid disease, smoking history, and higher preoperative CMS as predictors of delayed CSO achievement (HR, 1.01-6.41), whereas normal tendon on arthroscopy, defined as absence of tenosynovitis or tendon tear on arthroscopy, predicted earlier CSO achievement (HR, 0.19-0.46). Location of tenodesis and worker compensation status did not significantly predict the time to achieve CSOs on multivariate analysis.

Conclusion:

After isolated BT, patients can expect to attain CSO by 13 months postoperatively, with most patients achieving this between 5 and 8 months. Patients tend to take longer to achieve PASS than MCID and SCB.

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.

Clinical outcome comparison of suprapectoral and subpectoral tenodesis of the long head of the biceps with concomitant rotator cuff repair: A systematic review

BACKGROUND

Simultaneous repairs of rotator cuff and biceps tenodesis can be managed by tenodesis of long head of biceps tendon to a subpectoral or suprapectoral area. This review investigated long head of biceps tendon tenodesis with concomitant rotator cuff repair and evaluated the clinical outcomes and incidences of complications based on tenodesis location.

METHODS

Medline, Cochrane, and Embase databases were searched for published, randomized or nonrandomized controlled studies and prospective or retrospective case series with the phrases "suprapectoral," "subpectoral," "tenodesis," and "long head of biceps tendon". Those with a clinical evidence Level IV or higher were included. Non-English manuscripts, review articles, commentaries, letters, case reports, and sole long head of biceps tendon tenodesis articles were excluded.

RESULTS

From 481 studies, 13 were chosen. In total, 1194 subpectoral and 2520 suprapectoral tenodesis cases were investigated. Postoperative Constant-Murley and American Shoulder and Elbow Surgeons mean scores showed similar good results. In terms of complication incidences, while transient nerve injuries were more commonly seen in patients with subpectoral tenodesis, persistent bicipital pain and Popeye deformity are mostly seen in patients with suprapectoral tenodesis.

DISCUSSION

Biceps tenodesis to suprapectoral or subpectoral area with concomitant rotator cuff repair demonstrated similar outcomes. Popeye deformity and persistent bicipital pain were higher in suprapectoral area and transient neuropraxia was found to be higher in subpectoral area.Level of evidence: IV.

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.

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.

Long Head of the Biceps Tendon Ruptures: Biomechanics, Clinical Ramifications, and Management

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Pathology of the long head of the biceps tendon is a common source of shoulder pain and often occurs in combination with other shoulder disorders.

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Nonsurgical management, including rest and activity modification, use of nonsteroidal anti-inflammatory drugs, physical therapy, and corticosteroid injections, is usually the first line of treatment.

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Patients with symptoms that are refractory to nonsurgical management are indicated for biceps tenotomy or various tenodesis procedures.

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Although several studies have reported a higher incidence of "Popeye" deformity, muscle cramping, and pain in the bicipital groove postoperatively with tenotomy compared with tenodesis, there are no substantial differences in functional scores or patient satisfaction between the 2 techniques.

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To date, both tenotomy and tenodesis have been shown to be effective options in the management of long head of the biceps tendinopathy, and there are advantages to each procedure.

Predicting Patient Satisfaction With Maximal Outcome Improvement After Biceps Tenodesis

The goal of this study was to determine the threshold for achieving maximal outcome improvement (MOI) on the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and Constant-Murley (CM) questionnaires that predict satisfaction after isolated biceps tenodesis without concomitant rotator cuff repair. A retrospective analysis of prospectively collected data was performed for patients undergoing isolated biceps tenodesis from 2014 to 2017 at a single institution with minimum 6-month follow-up. Receiver operating characteristic curve analysis was used to determine thresholds for MOI for the ASES, SANE, and CM questionnaires. Stepwise multivariate logistical regression analysis was performed to identify predictors for achieving the threshold for MOI. A total of 123 patients were included in the final analysis. Receiver operating characteristic analysis determined that achieving 43.1%, 62.1%, and 61.4% MOI was the threshold for satisfaction for the ASES, SANE, and CM questionnaires, respectively. Regression analysis showed that concomitant superior labrum anterior-posterior (SLAP) repair was predictive of achieving MOI on the ASES and SANE questionnaires, whereas partial rotator cuff tear was predictive of achieving MOI on the CM questionnaire (P<.05 for both). Further, workers' compensation status, diabetes, history of ipsilateral shoulder surgery, and hypertension were negative predictors of achieving MOI on the SANE and CM questionnaires (P<.05 for all). Achieving MOI of 43.1%, 62.1%, and 61.4% is the threshold for satisfaction after biceps tenodesis for the ASES, SANE, and CM questionnaires, respectively. Concomitant SLAP repair was positively predictive of achieving MOI, whereas workers' compensation status, diabetes, history of ipsilateral shoulder surgery, and hypertension were negative predictors. [Orthopedics. 2021;44(3):e359-e366.].

Subpectoral versus suprapectoral biceps tenodesis yields similar clinical outcomes: a systematic review

IMPORTANCE

Arthroscopic suprapectoral biceps tenodesis (ABT) and open subpectoral biceps tenodesis (OBT) are two surgical treatment options for relief of long head of the biceps tendon (LHBT) pathology and superior labrum anterior to posterior (SLAP) tears. There is insufficient knowledge regarding the clinical superiority of one technique over the other.

OBJECTIVE

To systematically review the literature in order to compare the clinical outcomes and safety of ABT and OBT for treatment of LHBT or SLAP pathology.

EVIDENCE REVIEW

A systematic review was performed by searching PubMed, the Cochrane Library and Embase to identify studies that compared the clinical efficacy of ABT versus OBT. The search phrase used was: (bicep OR biceps OR biceps brachii OR long head of biceps brachii OR biceps tendinopathy) AND (tenodesis). Patients were assessed based on the American Shoulder and Elbow Surgeons Score, the visual analogue scale, the Single Assessment Numeric Evaluation, Constant-Murley Score, clinical failure, range of motion, bicipital groove pain and strength. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed, and both the Cochrane Collaboration's and Risk of Bias in Non-randomised Studies - of Interventions (ROBINS-I) risk of bias tools were used to evaluate risk of bias.

FINDINGS

Eight studies (one level I, seven level III) met inclusion criteria, including 326 patients undergoing ABT and 381 patients undergoing OBT. No differences were found in treatment failure rates or patient-reported outcome scores between groups in any study. One study found OBT patients to experience significantly increased range of shoulder forward flexion when compared with ABT patients (p=0.049). Two studies found ABT patients to experience significantly more postoperative stiffness when compared with OBT patients (p<0.05).

CONCLUSIONS

Patients undergoing ABT and OBT can be expected to experience similar improvements in clinical outcomes at latest follow-up without differences treatment failure or functional performance. ABT patients may experience an increased incidence of stiffness in the early postoperative period.

LEVEL OF EVIDENCE

III.

Failure rates and clinical outcomes after treatment for long-head biceps brachii tendon pathology: a comparison of three treatment types

Hypothesis/Background

Treatment options for the biceps brachii tendon include tenotomy, arthroscopic tenodesis, and open tenodesis. Few studies to date have compared all treatment options in the context of a rotator cuff repair.

Methods

A retrospective review of 100 patients who underwent arthroscopic supraspinatus repair between 2013 and 2018 with a minimum of one-year follow-up was performed. Patients were separated into the following 4 groups: (1) 57 had isolated supraspinatus repair with no biceps tendon surgery (SSP); (2) 16 had supraspinatus repair and biceps tenotomy; (3) 18 had supraspinatus repair and arthroscopic biceps tenodesis; (4) 9 had supraspinatus repair and an open biceps tenodesis (SSP + OT). The primary outcome was operative time. The secondary outcomes were cost analysis, complications, patient-reported outcome measures, range of motion, and strength testing.

Results

The operative time for the SSP + OT group was significantly longer than that of the SSP group (P < .05) but was not significantly longer than that of the other groups. The cost for the SSP group was significantly less than the cost for the SSP + OT and supraspinatus repair and arthroscopic biceps tenodesis groups (P < .05 for both), whereas the cost for the supraspinatus repair and biceps tenotomy group was significantly less than the cost for the SSP + OT group (P < .05). There were no significant differences between groups for complications, all patient-reported outcome measues, all range of motion, and all strength parameters.

Discussion/Conclusion

Operative time is the longest in open biceps tenodesis and is significantly longer than that of isolated supraspinatus repair. No significant differences in operative times or costs were identified in patients undergoing arthroscopic vs. open biceps tenodesis. All patients, irrespective of the type of biceps tendon procedure, had excellent clinical and functional outcomes at least one year after surgery. There was no difference in clinical or functional outcomes, or complications, among the 4 groups.

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.

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

BACKGROUND

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

KAToB: Knotless All-Arthroscopic Intraarticular Tenodesis of the Biceps, An Efficient, Simple, Reproducible Technique

Biceps tenodesis is a commonly performed procedure. It can be done using a multitude of fixation methods, at multiple locations, and either open or arthroscopic, with little if any clinical differences in the literature. Yet, many techniques have drawbacks in the risk of complications or in the technical ease. Here we present what we have found to be an efficient, simple, reproducible technique: KAToB, Knotless All-arthroscopic intraarticular Tenodesis of the Biceps using a knotless anchor at the articular margin. This technique minimizes the risk of nerve injury, infection, and fracture; has good clinical outcomes; and has a low rate of failure.

Influence of workers' compensation status on postoperative outcomes in patients following biceps tenodesis: a matched-pair cohort analysis

BACKGROUND AND HYPOTHESIS

Although the literature on the association of workers' compensation (WC) status with negative outcomes after orthopedic surgery is extensive, there is a paucity of evidence on outcomes in WC recipients undergoing biceps tenodesis. We hypothesized that WC patients would report significantly worse outcomes postoperatively on patient-reported outcome measures (PROMs).

METHODS

Functional and health-related quality-of-life PROMs and a visual analog scale score for pain were administered preoperatively and at 12 months postoperatively to consecutive patients undergoing isolated biceps tenodesis between 2014 and 2018 at our institution. Thirty-eight WC patients were matched 1:2 to non-WC patients by age, body mass index, and operative limb. The minimal clinically important difference, substantial clinical benefit, and patient acceptable symptom state were calculated for all patients via anchor- and distribution-based methods. Rates of achievement and the likelihood of achievement were determined.

RESULTS

All patients showed significant improvements in all outcome measures (P < .001). WC patients reported inferior postoperative scores on all PROMs examined. WC status significantly predicted a reduced likelihood of achieving substantial clinical benefit for the American Shoulder and Elbow Surgeons score (odds ratio [OR], 0.38; 95% confidence interval [CI], 0.17-0.81; P = .01) and the patient acceptable symptom state (OR, 0.28; 95% CI, 0.12-0.65; P = .003) for the American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation score (OR, 0.24; 95% CI, 0.10-0.61; P = .003), Constant-Murley Subjective Assessment (OR, 0.25; 95% CI, 0.08-0.77; P = .016), and visual analog scale pain score (OR, 0.27; 95% CI, 0.16-0.47; P < .001).

CONCLUSION

WC patients reported inferior scores on all postoperative PROMs and demonstrated lower odds of achieving substantial benefit and satisfaction regarding improvements in both function and pain compared with non-WC patients.

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.

Influence of mental health on postoperative outcomes in patients following biceps tenodesis

PURPOSE

To evaluate the relationship between preoperative mental health measured by the Short-Form 12 health survey mental component score and outcomes after isolated biceps tenodesis.

METHODS

The American Shoulder and Elbow Surgeons form (ASES), Single Assessment Numeric Evaluation (SANE), Constant-Murley score (CMS), and visual analog scale (VAS) for pain were administered preoperatively and at 6 and 12 months postoperatively to consecutive patients undergoing isolated biceps tenodesis between 2014 and 2018. Minimal clinically important difference, substantial clinical benefit (SCB), patient-acceptable symptom state (PASS), and rates of achievement were calculated. Patients were stratified by mental health status based on preoperative scores on the Short-Form 12 health survey mental component score. Multivariate logistic regression was performed to evaluate preoperative mental health status on achievement of minimal clinically important difference, SCB, and PASS.

RESULTS

Patients demonstrated significant improvements in all outcome measures (P < .001). Patients with depression reported inferior postoperative scores on all patient-reported outcome measures. Low preoperative mental health score significantly predicted reduced likelihood to achieve SCB (odds ratio [OR]: 0.38, 95% confidence interval [CI]: 0.17-0.81, P = .01) and PASS (OR: 0.28, 95% CI: 0.12-0.65, P = .003) on the ASES form, SANE (OR: 0.24, 95% CI: 0.10-0.61, P = .003), CMS (OR: 0.25, 95% CI: 0.08-0.77, P = .016), and VAS pain (OR: 0.01, 95% CI: 0.00-0.31, P = .008).

CONCLUSION

Patients with depression reported inferior scores on all postoperative patient-reported outcome measures and demonstrated lower odds of achieving the SCB and PASS on the ASES form and PASS on the SANE, CMS, and VAS pain, compared with nondepressed patients.

All-suture anchor and unicortical button show comparable biomechanical properties for onlay subpectoral biceps tenodesis

Hypothesis

The purpose of this study was to biomechanically evaluate onlay subpectoral long head of the biceps (LHB) tenodesis with all-suture anchors and unicortical buttons in cadaveric specimens.

Methods

After evaluation of bone mineral density, 18 fresh-frozen, unpaired human cadaveric shoulders were randomly assigned to 2 groups: One group received an onlay subpectoral LHB tenodesis with 1 all-suture anchor, whereas the other group received a tenodesis with 1 unicortical button. The specimens were mounted in a servo-hydraulic material testing system. Tendons were initially loaded from 5 N to 100 N for 5000 cycles at 1 Hz. Displacement of the repair constructs was observed with optical tracking. After cyclic loading, each specimen was loaded to failure at a rate of 1 mm/s.

Results

The mean displacement after cyclic loading was 6.77 ± 3.15 mm in the all-suture anchor group and 8.41 ± 3.17 mm in the unicortical button group (P = not significant). The mean load to failure was 278.05 ± 38.77 N for all-suture anchor repairs and 291.36 ± 49.69 N for unicortical button repairs (P = not significant). The most common mode of failure in both groups was LHB tendon tearing. There were no significant differences between the 2 groups regarding specimen age (58.33 ± 4.37 years vs. 58.78 ± 5.33 years) and bone mineral density (0.50 ± 0.17 g/cm² vs. 0.44 ± 0.19 g/cm²).

Conclusion

All-suture anchors and unicortical buttons are biomechanically equivalent in displacement and load-to-failure testing for LHB tenodesis. All-suture anchors can be considered a validated alternative for onlay subpectoral LHB tenodesis.

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.

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.

The Elongation of Biceps Muscle Tendon Unit After Rerouting of the Long Head of Biceps Tendon as Superior Capsular Augmentation: A Quantitative Measurement

Purpose

The purpose of this study was to investigate the elongation of the biceps muscle tendon unit after rerouting of the long head of the biceps tendon without transection, with and without release of the transverse humeral ligament in a 3-dimensional model.

Methods

A total of 60 sets of computed tomography images of shoulders were acquired, and a point-cloud model was generated after 3-dimensional reconstruction. Simulation of rerouting of the long head of the biceps tendon was performed by assuming that the long head of the biceps tendon travels to the center of the greater tuberosity from the supraglenoid tubercle and then back to the bicipital groove distally, with or without the release of the transverse humeral ligament. The elongation of the biceps muscle tendon unit by both manners was measured and correlated with age, height, weight, body mass index, gender, and hand dominance.

Results

The mean length of the long head of the biceps tendon is 74.22 ± 3.06 mm, and the length is significantly longer, at 112.23 ± 4.92 mm (P = 0.0002) and 96.47 ± 2.58 mm (P = 0.0004). The absolute elongation of the biceps muscle tendon unit after rerouting of the long head of the biceps tendon, without or with transverse humeral ligament release, showed significant differences, which were 38.73 ± 3.03 mm and 22.28 ± 3.25 mm, respectively (P = 0.0008). No significant correlations were observed between the amount of the elongation and the subject's age, height, weight, or body mass index. No significant difference was observed in the amount of the elongation between differing gender and hand dominance.

Conclusions

Rerouting of the long head of the biceps tendon resulted in significant elongation of the biceps muscle tendon unit. Release of the transverse humeral ligament partially decreased this elongation.

Clinical Relevance

Rerouting of the long head of the biceps tendon may lead to overtension of the biceps. If it is adopted in clinical use, transverse humeral ligament release is recommended.

Costs, Complications, and Reoperations Associated With Primary Arthroscopic Rotator Cuff Repair With or Without Acromioplasty and/or Biceps Tenodesis

Purpose

To evaluate the reoperations, complications, and costs up to 5 years following arthroscopic rotator cuff repair (RCR) alone, with acromioplasty (acro), with biceps tenodesis (BT), or with both acro and BT.

Methods

We queried the MarketScan database to identify patients who underwent RCR from 2007 to 2016. Patients were stratified into groups based on concomitant procedures (acro and/or BT) performed on the same day as index RCR. Reoperations, complications, and costs were followed for 5 years post-index procedure. Patients without laterality codes were excluded. A multivariate logistic regression analysis was used to control for confounding factors.

Results

This study identified 147,838 patients (mean age, 53.1 years; standard deviation, 8.3 years) who underwent primary RCR. Patients were stratified into 4 groups: (1) RCR only, (2) RCR + acro, (3) RCR + BT, and (4) RCR + acro + BT. Patients in the RCR only group experienced the highest rate of unadjusted overall postoperative complications (17.2%) versus the other groups (RCR + acro 16.4%, RCR + BT 15.1%, RCR + acro + BT 16.2%, P < .0161). The RCR only group also experienced a significantly greater number of reoperations on the ipsilateral shoulder (P < .0001), whereas the RCR + acro + BT had the highest costs at all timepoints. In the regression analysis, there was no significant differences between complications and reoperations between any groups. After adjusting for covariates, the performance of a BT with an RCR and acromioplasty led to increased costs (odds ratio, 1.47, 1.37-1.59, P < .001).

Conclusions

Concomitant biceps tenodesis does lead to higher total healthcare costs, both in the shorter and longer terms. When adjusting for confounding factors, the performance of concomitant biceps tenodesis with rotator cuff repair does not lead to a difference in postoperative complication rate or risk for revision surgery.

Level of Evidence

Level IV, economic analysis.

Minimal clinically important differences after subpectoral biceps tenodesis: definition and retrospective assessment of predictive factors

BACKGROUND

Minimal clinically important differences (MCIDs) at 1 year after subpectoral biceps tenodesis are unknown for the American Shoulder and Elbow Surgeons (ASES) scale, Subjective Shoulder Value (SSV), and visual analog scale (VAS) for pain. Our objectives were to determine MCIDs for these measures at 1 year after biceps tenodesis and to identify preoperative factors that predict attainment of MCIDs.

METHODS

We included 52 patients who underwent arthroscopic débridement, decompression, and mini-open biceps tenodesis from 2016-2018. We analyzed age, sex, body mass index value, arm dominance, diagnosis, range of shoulder motion, and preoperative and 1-year postoperative ASES, SSV, and VAS scores. MCIDs were calculated using a distribution-based method of one-half the standard deviation. Preoperative thresholds predictive of MCIDs were calculated with univariate logistic regression. Multiple logistic regression was used to determine factors that predict MCIDs. Significance was set at a 2-tailed P value of <.05.

RESULTS

MCIDs for the ASES, SSV, and VAS were 13, 12, and 1.6 points, respectively. Preoperative ASES score <59 predicted MCID on the ASES (P = .03); VAS score >3 predicted MCID on the VAS (P < .01); external shoulder rotation >40° predicted MCID on the SSV (P = .02); and age >41 years predicted MCID on the VAS (P = .02).

CONCLUSION

At 1 year after débridement, decompression, and biceps tenodesis, MCIDs were 13, 12, and 1.6 points for the ASES, SSV, and VAS, respectively. Patients most likely to attain MCIDs were those aged >41 years, those with the most preoperative pain, and those with the poorest preoperative shoulder function.

Medial Dislocation of the Long Head of the Biceps without Concomitant Subscapularis Tear: A Case Report

Introduction

Medial dislocation of the long head of the biceps tendon (LHBT) is classically known as a pathognomonic finding for a subscapularis or at least a rotator cuff (RC) injury. However, this case report outlines a young active individual with symptomatic medial dislocation of the long head of the biceps with associated posterior instability, without a corresponding RC injury.

Case Report

An 18-year-old male complained of the left shoulder pain and crepitus after a shoulder injury while playing hockey a year prior. Magnetic resonance imaging demonstrated medial dislocation of the LHBT without subscapularis or supraspinatus tendon injury. The patient complained of instability in the shoulder and exam findings supported posterior instability of the glenohumeral joint. Arthroscopic debridement of the glenohumeral joint with arthroscopic posterior capsulorrhaphy and open biceps tenodesis was performed. The patient regained full and painless range of motion at 2-year follow-up.

Conclusion

Medial dislocation of the LHBT can occur without injury to the subscapularis tendon. Furthermore, a capsulorrhaphy with open biceps tenodesis and closure of the rotator interval may provide a successful outcome for this rare injury pattern.

Relationship between the Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive testing and legacy instruments in patients undergoing isolated biceps tenodesis

HYPOTHESIS

The purpose of this study was to correlate the Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive testing (CAT) domains with commonly used legacy patient-reported outcome measures (PROMs) preoperatively in a population of patients presenting to a tertiary care orthopedic center for biceps and labral pathology.

METHODS

Prospective data were collected on 175 patients scheduled to undergo isolated biceps tenodesis at a tertiary center. Enrollees completed legacy scores (Veterans RAND 12-Item Health Survey, Short Form 12, American Shoulder and Elbow Surgeons [ASES] Assessment Form, Single Assessment Numeric Evaluation, and Constant-Murley score) and PROMIS CAT questionnaires (Upper Extremity [UE], Pain Interference [PIF], and Depression). In addition, patients were asked to provide an assessment of the strength, function, and pain of the affected shoulder using a custom visual analog scale (VAS) questionnaire. Spearman rank correlations of the PROMIS CAT with legacy measures and the custom VAS were calculated. Floor and ceiling effects were assessed.

RESULTS

The UE CAT yielded moderate correlations with the ASES score (r = 0.57) and the custom VAS strength score (r = 0.50-0.57). The PIF CAT demonstrated moderate correlations with the VAS pain score (r = 0.45) and high-moderate correlations with the ASES score, VR6D score, and UE CAT (r = 0.61-0.66). The Depression CAT demonstrated high-moderate correlations with the mental health legacy measures (r = -0.64 to -0.61). There was a significant relative floor effect for the Depression CAT at a score of 34.2 (19%).

CONCLUSION

The PIF CAT was comparable to the ASES score, the current gold standard. Compared with legacy measures, both the UE CAT and PIF CAT are less burdensome and have few floor or ceiling effects. The PIF CAT may be a viable alternative to describe the physical and psychosocial impact of pain in biceps tenodesis patients.

Surgical treatment for long head of the biceps tendinopathy: a network meta-analysis

BACKGROUND

Surgical options for pathology affecting the long head of the biceps tendon (LHBT) include tenotomy and tenodesis, both of which can be performed with a variety of fixation methods. This study aimed to compare surgical treatment options for LHBT lesions using a network meta-analysis of published clinical studies.

METHODS

A systematic review of the literature was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Clinical studies comparing surgical treatment options for LHBT lesions were included. Postoperative outcomes were compared between surgical treatment options using a frequentist approach to network meta-analysis.

RESULTS

There were 22 studies comparing surgical treatment options for LHBT pathology including arthroscopic tenotomy, arthroscopic suprapectoral tenodesis, arthroscopic intracuff tenodesis, and open subpectoral tenodesis, consisting of 1804 patients. Compared with arthroscopic tenotomy, open subpectoral tenodesis resulted in a significantly greater American Shoulder and Elbow Surgeons score (mean difference, 4.58; P = .014). On the basis of the P-score, all 3 tenodesis techniques ranked above tenotomy with respect to the Constant score. Compared with arthroscopic tenotomy, the incidence of Popeye deformity was reduced with arthroscopic suprapectoral tenodesis (odds ratio [OR], 0.23; P < .001) and open subpectoral tenodesis (OR, 0.25; P = .022). The incidence of bicipital groove pain was increased after arthroscopic intracuff tenodesis (OR, 2.89; P = .021) compared with arthroscopic tenotomy.

CONCLUSION

Lesions of the LHBT treated with open or arthroscopic tenodesis resulted in comparatively superior functional outcomes and a lower incidence of Popeye deformity, whereas arthroscopic intracuff tenodesis resulted in a higher incidence of bicipital groove pain.

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.

Editorial Commentary: Biceps Tenodesis Fixation: Screw, Button, or None of the Above?

Clinical outcomes following shoulder subpectoral biceps tenodesis are generally favorable, with a very low complication rate (2%). One of the most devastating complications following this procedure is the occurrence of a proximal humerus fracture. Although all constructs have their unique advantages and disadvantages, creating a smaller bone hole while achieving good biomechanical outcomes is worth considering. This may be most advantageous in overhead-throwing athletes, tennis players, and/or volleyball athletes, who subject their shoulders to more torsional load due to the requirements of their sport. Thus, in addition to screws and buttons, smaller-diameter suture anchors could also be thoughtfully considered as a biceps tenodesis fixation option.