All-arthroscopic suprapectoral versus open subpectoral tenodesis of the long head of the biceps brachii

Clinical Outcome of an All Arthroscopic 'Whole Layer' Rotator Cuff Repair Technique with Simultaneous Biceps Tenodesis

OBJECTIVE

To retrospectively evaluate clinical outcomes, including function and pain, of patients after our all arthroscopic "whole layer" rotator cuff repair technique with simultaneous biceps tenodesis procedure; factors influencing results were also evaluated. Given the frequent association of rotator cuff tear with long head of biceps lesion and the need for effective combined treatment strategies, this study aims to evaluate the efficacy of our technique and compare it with established methods. We hypothesized that our technique would significantly improve function and reduce pain in patients with rotator cuff tears and biceps pathology.

METHODS

This is a retrospective study that included patients older than 20 years who underwent all arthroscopic "whole layer" rotator cuff repair technique with simultaneous biceps tenodesis procedures for concomitant rotator cuff tear and long head biceps pathology, from 2016 to 2020. Patients were evaluated preoperatively and at a minimum of 2 years of follow-up using the American Shoulder and Elbow Surgeons (ASES) and visual analogue scale (VAS) scores paired t-tests were used for analysis and statistical significance was set at p < 0.05(two-tailed). The satisfaction rate and complications were also evaluated.

RESULTS

After an average follow-up of 2.3 years, 118 patients demonstrated significant improvement in both the ASES score (from 36.13 to 95.01, p < 0.001) and VAS score (from 6.81 to 0.89, p < 0.001). Ninety-four percent of the patients reported satisfaction with the surgical outcome. No complications related to Popeye deformity, biceps cramping pain, or ipsilateral shoulder reoperation were observed. Factors such as age, sex, body mass index (BMI), smoking status, alcohol consumption, hypertension, and diabetes did not influence the results. Patients showed significant improvement in both the ASES and VAS scores (p < 0.001).

CONCLUSION

At a mean follow-up time of 2.3 years, the all arthroscopic "whole layer" rotator cuff repair technique with simultaneous biceps tenodesis is a therapeutic and efficient procedure. The procedure revealed a satisfactory functional outcome, reduced pain, and minimal complications and reoperations.

Repair of Isolated Subscapularis Tears With Concurrent Biceps Tenodesis Using a Single Anchor Results in Satisfactory Clinical Outcomes: Minimum 2-Year Follow-Up

PURPOSE

To investigate the clinical outcomes of patients treated with isolated subscapularis tear repair and biceps tenodesis using a single anchor.

METHODS

Patients diagnosed with subscapularis tear and who underwent arthroscopic surgery by a single surgeon between February 2017 and January 2022 were evaluated retrospectively. Inclusion criteria were patients who underwent repair of isolated subscapularis tear along with tenodesis for long head of the biceps tendon pathologies such as SLAP lesion, instability, partial tear, or tenosynovitis, with a minimum follow-up of 24 months. Assessment included active and passive range of motion, single-assessment numeric evaluation (SANE), visual analog scale (VAS), Constant-Murley score (CMS), and specific subscapularis and biceps tests. Improvements were analyzed using minimum clinically important difference (MCID) values.

RESULTS

A total of 20 patients were included. The mean age was 48.5 ± 7 years, and the follow-up period was 43.1 ± 12.7 months. Significant improvements were observed at the final follow-up in active forward flexion, active abduction, active internal rotation, as well as VAS, SANE, and CMS (P < .001). The MCID analysis showed that 100% of patients met the MCID for CMS, 90% for SANE, and 100% for VAS.

CONCLUSIONS

In the presence of an isolated subscapularis tear associated with long head of the biceps tendon pathologies, favorable clinical outcomes could be achieved by performing both tear repair and biceps tenodesis with a double-loaded single anchor. Most patients (>90%) achieved the MCID for the CMS, SANE, and VAS, indicating significant clinical improvement and satisfactory patient outcomes.

LEVEL OF EVIDENCE

Level IV, case series.

Variations in subpectoral biceps tenodesis locations do not impact clinical outcomes

Background

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

Methods

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

Results

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

Discussion

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

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 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.

Arthroscopic Suprapectoral Biceps Tenodesis Using Standard Portals

The long head of the biceps (LHB) tendon is a common cause of shoulder pain. Biceps tenodesis is commonly used to address biceps and superior labrum pathology, reducing pain and restoring function. There are numerous techniques for biceps tenodesis, and it is unclear as to which single technique and approach provides significantly superior outcomes. In this technical note, we present an arthroscopic suprapectoral approach with release of the LHB from the bicipital groove and subsequent fixation with suture anchor. This technique simplifies the technique to be performed from standard arthroscopic portals and aims to maximize outcomes and minimize common complications associated with biceps tenodesis.

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.

Biceps Tenodesis Better Improves the Shoulder Function Compared with Tenotomy for Long Head of the Biceps Tendon Lesions: A Meta-Analysis of Randomised Controlled Trials

PURPOSE

Surgical options for long head of the biceps tendon (LHBT) lesions include tenotomy and tenodesis. This study aims to determine the optimal surgical strategy for LHBT lesions with updated evidence from randomised controlled trials (RCTs).

METHODS

Literature was retrieved from PubMed, Cochrane Library, Embase and Web of Science on 12 January 2022. Randomised controlled trials (RCTs) comparing the clinical outcomes of tenotomy and tenodesis were pooled in the meta-analyses.

RESULTS

Ten RCTs with 787 cases met the inclusion criteria, and were included in the meta-analysis. Constant scores (MD, -1.24; p = 0.001), improvement of Constant scores (MD, -1.54; p = 0.04), Simple Shoulder Test (SST) scores (MD, -0.73; p = 0.03) and improvement of SST (p < 0.05) were significantly better in patients with tenodesis. Tenotomy was associated with higher rates of Popeye deformity (OR, 3.34; p < 0.001) and cramping pain (OR, 3.36; p = 0.008]. No significant differences were noticed between tenotomy and tenodesis regarding pain (p = 0.59), American Shoulder and Elbow Surgeons (ASES) score (p = 0.42) and its improvement (p = 0.91), elbow flexion strength (p = 0.38), forearm supination strength (p = 0.68) and range of motion of shoulder external rotation (p = 0.62). Subgroup analyses showed higher Constant scores in all tenodesis types and significantly larger improvement of Constant scores regarding intracuff tenodesis (MD, -5.87; p = 0.001).

CONCLUSIONS

According to the analyses of RCTs, tenodesis better improves shoulder function in terms of Constant scores and SST scores, and reduces the risk of Popeye deformity and cramping bicipital pain. Intracuff tenodesis might offer the best shoulder function as measured with Constant scores. However, tenotomy and tenodesis provide similar satisfactory results for pain relief, ASES score, biceps strength and shoulder range of motion.

Does the timing of tenotomy during biceps tenodesis affect the incidence of Popeye deformity and clinical outcome? An analysis of short-term follow-up of 2 techniques

BACKGROUND

There are multiple techniques that attempt to maintain anatomic length-tension relationship during biceps tenodesis. However, no direct comparison has been performed with respect to the timing of biceps tenotomy during biceps tenodesis. This study aims to assess the incidence of Popeye deformity and clinical outcomes of 2 all-arthroscopic techniques for biceps tenodesis based on timing of the biceps tenotomy.

METHODS

A consecutive series of patients undergoing arthroscopic biceps tenodesis with concomitant rotator cuff tears were enrolled from 2019 to 2021. Biceps tenodesis performed after tenotomy formed the first cohort (group 1). The other cohort had biceps tenodesis performed prior to biceps tenotomy (group 2). Postoperative anterior arm pain, biceps muscle spasms, and patient perceptions of the appearance of the bicep muscle were assessed. In addition, patient-reported outcomes (PROs) were collected at 3 months and minimum 6 months postoperatively.

RESULTS

A total of 71 patients were eligible for participation and 62 patients (53% female, age 58.7 ± 9.0 years) were enrolled (n = 33 in group 1, and n = 29 in group 2). There were no differences between groups with respect to gender, age, and laterality of biceps tenodesis, as well as type and size of rotator cuff repair. At 3-month follow-up, Veterans RAND 12-Item Health Survey (VR-12) physical health summary scores were significantly improved in group 2 (44.8 ± 9.7) compared with group 1 (34.1 ± 3.4) (P = .03). In addition, patients in group 2 experienced significantly less pain in their anterior arm than patients in group 1 (19% vs. 33%, P = .02). There were no differences in biceps muscle spasm (3.4% vs. 5.2%, P = .21) and no other differences in PROs between groups. Final follow-up averaged 11.6 ± 3.3 months in group 1 and 11.8 ± 5.5 months in group 2. There were no significant differences in patient-perceived biceps Popeye deformity between group 1 (12.1%) and group 2 (0%) (P = .652). Furthermore, there were no differences in American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, EuroQol-5 Dimension, Patient-Reported Outcomes Measurement Information System Global Health (PROMIS 10) physical health, PROMIS 10 depression, VR-12 physical health summary, and Single Assessment Numeric Evaluation scores between the 2 technique groups.

CONCLUSION

Patients with tenotomy performed after tenodesis had better VR-12 physical health summary scores and less arm pain than patients with tenotomy performed before tenodesis at 3-month follow-up. However, there were no differences in any outcome at final follow-up of nearly 1-year. In addition, there were no differences in perceived Popeye deformity between groups at any time period.

The high resistance loop (H-loop) technique used for all-inside arthroscopic knotless suprapectoral biceps tenodesis: A case series

Introduction

Suprapectoral tenodesis is a common technique for the treatment of long head biceps tendon lesions. However, so far, there is no gold standard treatment in all-inside arthroscopy. The purpose of the present study was to introduce and evaluate the functional outcomes of an innovative, all-inside arthroscopic high resistance loop (H-loop, high resistance to tissue cutout and 360° grasping of the tendon) technique for long head of biceps (LHB) tenodesis.

Method

From September 2020 to March 2022, a series of cases of 32 consecutive patients (28 rotator cuff tear with LHBT pathology and 4 superior labrum anterior-posterior (SLAP) tears which including 2 type II and 2 type IV) who received LHB tenodesis using all-inside arthroscopic high resistance loop technique were included in this study. The American Shoulder and Elbow Surgeon Score (ASES), Visual Analog Scale (VAS), Simple Shoulder Test Score (SST), Constant–Murley scores, and University of California at Los Angeles Scoring System (UCLA) were used to evaluate the clinical outcomes of patients in preoperative and final follow-up. Meanwhile, postoperative complications were also observed.

Result

32 patients (14 women and 18 men, average age was 55.7 years) underwent all-inside arthroscopic knotless suprapectoral biceps tenodesis using the H-Loop stitch technique. The mean time of follow-up was 16.2 ± 2.6 months. The ASES, VAS, Constant–Murley, SST, and UCLA scores improved from 51.5 ± 15.8, 5.5 ± 1.6, 57.8 ± 14.7, 5.0 ± 2.8, and 16.1 ± 3.8 preoperatively, to 89.1 ± 7.5, 1.0 ± 0.8, 87.3 ± 5.5, 10.4 ± 1.5, and 31.3 ± 2.6 in the last follow-up, respectively (p < 0.001). During the follow-up, no patients in this study experienced postoperative complications such as infection of the wound, injury of nerves, and hardware failure; no patients required revision after their operation. In addition, none of the patients had cramping or a “Popeye” deformity during follow-up.

Conclusion

This article presents an innovative, all-arthroscopic H-loop technique for LHB tenodesis. This technique for LHB tenodesis showed favorable functional and cosmetic outcomes, as well as high satisfaction rates. Due to its simplicity of operation and satisfactory preliminary clinical outcomes, H-loop technique is perhaps another option to choose in all-inside arthroscopic LHB tenodesis.

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).

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

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

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.

Can a Two Simple Stitches Method Provide Secure Fixation Strength in Biceps Tenodesis?: Biomechanical Evaluation of Various Suture Techniques

Background

The purpose of this study was to compare the initial fixation strength between four different suture methods for the long head of the biceps.

Methods

Forty-eight fresh frozen porcine flexor hallucis longus tendons (mean width at suture site, 8.5 ± 0.9 mm) and phalanx bones were randomly assigned to one of the four arthroscopic biceps tenodesis techniques: simple stitch (SS), mattress suture (MS), lasso-loop (LL), and two simple stitches (2SS). A biceps tenodesis was performed according to the four techniques using all-suture type suture anchors (1.9-mm SUTUREFIX anchor with No. 1 ULTRABRAID sutures). Biomechanical evaluations were performed to test load to failure (N), stiffness (N/mm), stress (N/m²), and mode of failure.

Results

As for the SS, MS, LL, and 2SS, the mean load to failure was 50.9 ± 14.61 N, 82.3 ± 24.8 N, 116.2 ± 26.7 N, and 130.8 ± 22.5 N (p < 0.001), respectively; mean stiffness was 6.1 ± 1.3 N/mm, 6.7 ± 2.6 N/mm, 7.8 ± 1.4 N/mm, and 8.1 ± 4.2 N/mm, respectively (p = 0.258); and mean stress was 0.7 ± 0.3 N/m², 1.4 ± 0.8 N/m², 2.9 ± 0.7 N/m², and 2.7 ± 0.8 N/m², respectively (p < 0.001). All the failures happened by the suture cutting through the tendon along its longitudinal fibers.

Conclusions

Neither the SS nor the MS method was enough to securely fix the biceps tendon with a significantly lower mechanical strength; however, the 2SS method showed similar initial fixation strength as the LL technique.

Isolated Biceps Tenodesis and Tenotomy: A Systematic Review of Indications and Patient Satisfaction

Biceps tenodesis and tenotomy are increasingly being used as treatment options for shoulder pathology, but patient satisfaction remains largely unstudied. A systematic review of the MEDLINE database was conducted to identify clinical outcome studies on isolated biceps tenodesis or tenotomy that reported patient satisfaction. Within the 15 investigations that were included, the indication for tenotomy was rotator cuff pathology, whereas the indication for tenodesis was biceps pathology or type 2 superior labral tear from anterior to posterior. Patients undergoing tenotomy were 13.6 years older than those undergoing tenodesis (P<.001). Patient satisfaction was high following both procedures, at 85.6% following tenotomy and 92.3% following tenodesis. [Orthopedics. 2021;44(6):333-340.].

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 biceps tenotomy versus tenodesis: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To compare tenotomy versus tenodesis for the treatment of long head of the biceps tendon pathologies. The primary outcome was the shoulder functional outcome. The secondary outcomes consisted of postoperative pain, elbow flexion and forearm supination strengths and postoperative complications.

METHODS

PubMed, MEDLINE, Google Scholar and Web of Science were searched until April 2020. Included studies were randomized controlled trials with a minimum 12 months' follow-up.

RESULTS

Both treatments had similar improvement on the Constant-Murley score at 6 months and 12 months. However, tenotomy had a significantly lower Constant-Murley score at two years with a mean difference of -1.13 (95% confidence interval -1.9, -0.35). Furthermore, tenotomy had a risk ratio of 2.46 (95% confidence interval 1.66, 3.64) for developing Popeye's deformity. No significant difference was detected in other functional outcomes, pain, or elbow flexion and forearm strength indices.

DISCUSSION

Tenodesis and tenotomy are both well-established techniques that similarly yield satisfactory outcomes. Despite that tenodesis had a statistically significant better Constant-Murley score at two years, this was clinically irrelevant. With the current evidence, we recommend either technique for the management of the long head of the biceps tendon pathologies.

LEVEL OF EVIDENCE

Therapeutic, Level II.

Early Versus Delayed Active Range of Motion After Open Subpectoral Biceps Tenodesis

Background

Little is known regarding the effect of early active elbow range of motion (ROM) protocols on failure rates and outcomes after open subpectoral biceps tenodesis.

Hypothesis

We hypothesized that patients managed using an early active ROM protocol after open subpectoral biceps tenodesis would demonstrate similar failure rates and functional outcomes compared to patients managed using a traditional delayed active ROM protocol.

Study Design

Cohort study; Level of evidence, 3.

Methods

We evaluated 63 patients who underwent open subpectoral biceps tenodesis with unicortical suture button fixation. Based on surgeon preference, 22 patients were managed using an early active motion protocol consisting of no restrictions on elbow flexion or forearm supination, while 41 patients were managed using a delayed motion protocol postoperatively. Primary outcome measures included failure of biceps tenodesis and American Shoulder and Elbow Surgeons (ASES) and Single Assessment Numeric Evaluation (SANE) scores. Secondary outcomes included shoulder and elbow ROM at 6 months postoperatively.

Results

The mean follow-up for the 63 patients was 24.2 months postoperatively. One patient (2.4%) in the delayed active motion cohort and no patients in the early active motion cohort experienced failure. Final outcome scores as well as 6-month shoulder and elbow ROM indicated excellent functional outcomes, with no significant difference between motion cohorts. The median postoperative ASES scores were 97.99 in the early active motion cohort (mean ± standard deviation [SD], 95.49 ± 7.68) and 95.42 in the delayed motion cohort (mean ± SD, 90.93 ± 16.08), while median postoperative SANE scores were 96 in the early motion cohort (mean ± SD, 94.23 ± 6.68) and 95 in the delayed motion cohort (mean ± SD, 88.39 ± 17.98). Subgroup analysis demonstrated no significant difference in outcome scores based on the performance of concomitant rotator cuff repair or hand dominance.

Conclusion

Early active ROM after open subpectoral biceps tenodesis with unicortical suture button fixation resulted in low failure rates and excellent clinical outcomes, comparable to the results of patients managed using delayed active ROM protocols. This suggests that patients undergoing open subpectoral biceps tenodesis may be managed using either early or delayed active motion protocols without compromising functional outcome.

Short-Term Clinical and Return-to-Work Outcomes After Arthroscopic Suprapectoral Onlay Biceps Tenodesis With a Single Suture Anchor

Purpose

To describe short-term outcomes of arthroscopic suprapectoral onlay biceps tenodesis using a single all-suture anchor with respect to validated outcome measures, return to work, objective strength and motion data, and biceps-specific testing.

Methods

This study describes a consecutive series of patients undergoing arthroscopic suprapectoral onlay biceps tenodesis performed by a single surgeon from January to December 2017. Patients were evaluated preoperatively and postoperatively with the American Shoulder and Elbow Surgeons questionnaire, visual analog scale, Single Assessment Numeric Evaluation, Veterans RAND 12-Item Health Survey, and 12-Item Short Form survey, and return-to-work survey. Postoperative strength, range of motion, and biceps-specific testing was also performed.

Results

This study included 50 patients (26 men and 24 women), with an average age (± standard deviation) of 50.1 ± 10.9 years and average final follow-up of 21.3 ± 8.5 months. Among employed patients, 32 (71.1%) returned to work at an average of 4.6 ± 2.3 months. Light-duty workers returned to work at a significantly greater rate (85.7% vs 33.3%, P = .016) and in less time (2.6 ± 2.0 months vs 6.8 ± 4.2 months) than heavy-duty workers. No differences were found between operative and nonoperative sides in the biceps apex distance (P = .636) or range of motion in elbow flexion and extension (P > .9 for both), supination (P = .192), or pronation (P = .343) postoperatively. Strength in elbow flexion (P = .002), as well as shoulder forward elevation (P < .001) and external rotation (P < .001), increased postoperatively. Significant patient-reported improvements were noted in the American Shoulder and Elbow Surgeons score, visual analog scale pain score, Single Assessment Numeric Evaluation score, Constant-Murley score, and Veterans RAND 12-Item Health Survey and 12-Item Short Form physical component scores (P ≤ .001 for all). A postoperative Popeye deformity developed in 5 patients (10%).

Conclusions

Arthroscopic suprapectoral onlay biceps tenodesis with a single all-suture anchor can provide overall excellent clinical outcomes regarding strength, motion, and validated patient-reported outcome questionnaires. Return to occupational activities may be less predictable and more prolonged for heavy laborers. A small number of patients may experience cosmetic deformity postoperatively.

Level of Evidence

Level IV, therapeutic case series.

Use of Novel Radiofrequency Wand for the Application of the Biceps Tenotomy and Subacromonical Bursectomy

Rotator cuff tears in patients can lead to a surgical intervention to relieve the pain and improve the function of the shoulder joint. In the majority of cases, the rotator cuff repair is completed arthroscopically and requires the ability for soft-tissue resection and visualization to restore the anatomic structures to their native state. With the advent of a radiofrequency wand, the technical aspects of a biceps tenotomy from the insertion point on the glenoid can be completed, along with the ability to resect, ablate, and coagulate tissue, using a single instrument. Although bone resection is completed with a bone cutting shaver and/or burr, the soft-tissue dissection can be completed in a precise and efficient manner.

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.

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.

The "Sandwich Tenodesis": An Arthroscopic Technic for Combined Soft-Tissue and Bony Fixation of the Long Head of the Biceps

Pathology of the long head of the biceps can contribute to substantial shoulder pain. After nonoperative treatment has failed, either open or arthroscopic tenotomy or tenodesis can be recommended depending on age, occupation, function, and cosmetic preference. While classic tenodesis techniques rely on tendon-to-bone fixation, multiple studies have shown superior healing results for fixation between similar types of tissue, such as tendon-to-tendon. In this technique, we present the "sandwich technique," performed entirely arthroscopically. A single 4-strand anchor with bioabsorbable screw is used to provide 2 types of fixation. Two strands are first used to lasso-loop the long head of the biceps to the bicipital groove, providing bone-to-tendon fixation. The other strands are then used to anchor rotator interval tissue to the tendon, providing a similar tissue or tendon-to-tendon patch augmentation.

Trends in the Treatment of Biceps Pathology: An Analysis of the American Board of Orthopaedic Surgery Database

Background:

Long head of biceps tendon pathology is a well-described source of pain in the anterior adult shoulder. Shoulder arthroscopic surgeons face this condition on a frequent basis because of the increasing aging population. Trends in treatment for this condition have varied over recent decades. An understanding of these trends may help orthopaedic surgeons counsel these patients.

Purpose:

To evaluate trends in treatment selection, patient population, and complications in recent part II examinees of the American Board of Orthopaedic Surgery (ABOS) board examination.

Study Design:

Cross-sectional study.

Methods:

Using a database maintained by the ABOS, we accessed and analyzed examinee data from 2008 to 2019 to evaluate trends in the following categories: examination year/subspecialty, region, patient age/sex, International Classification of Diseases code, Current Procedural Terminology code, and complications. These data points were analyzed for all board-eligible candidates from 2008 to 2019.

Results:

The annual number of proximal biceps tendon (PBT) procedures performed increased significantly from 597 cases in 2008 to 2203 cases in 2019 (P < .001). Incidence of biceps tendon tenotomy significantly decreased between the years 2007 and 2018 (P < .001). Both open and arthroscopic biceps tenodesis significantly increased between 2007 and 2018 (P < .001). Most PBT cases were performed simultaneously with other procedures (17,283/17,861; 96.8%). The most common PBT procedure performed overall was open tenodesis of long tendon of biceps (∼60.8%). Complication rates for PBT procedures reported each year did not significantly change between 2007 and 2018 (7.5% vs 9.7%; P = .103).

Conclusion:

PBT procedures are being increasingly performed among recently trained orthopaedic surgeons. Proximal biceps tenotomy has significantly declined, whereas proximal biceps tenodesis, open or arthroscopic, has significantly increased, demonstrating a possible shift in the standard of care among new surgeons.

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

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

Biceps Squeeze Tenotomy: Technique to Improve Efficiency of Arthroscopic Biceps Tenotomy

Biceps tenotomy is a common procedure performed in arthroscopic shoulder surgery. Numerous studies have demonstrated the effectiveness of both biceps tenotomy and tenodesis to relieve pain and restore function for the diagnoses of bicipital tenosynovitis, SLAP tears, rotator interval pulley lesions, and failed SLAP repairs. It is also frequently performed as a concomitant procedure with arthroscopic rotator cuff repair. We report a technique to improve the efficiency of arthroscopic bicep tenotomy using a biceps squeeze maneuver. This is a simple method of manually squeezing the biceps muscle belly while performing the arthroscopic biceps tenotomy. This shortens and tensions the intra-articular portion of the tendon to facilitate a more safe and efficient procedure.

Clinical Outcomes of an All-Arthroscopic Biceps Tenodesis Using the Anterolateral Anchor During Concomitant Double-Row Rotator Cuff Repair

Background:

Pathology of the long head of the biceps tendon frequently occurs concomitantly with rotator cuff tears, necessitating a surgical treatment, often in the form of a tenodesis procedure. Many techniques for a tenodesis exist; however, they often require additional implants or a separate incision.

Purpose:

To report an average of 2-year outcomes of an all-arthroscopic biceps tenodesis employing the stay sutures from the anterolateral anchor during concomitant double-row rotator cuff repair (RCR).

Study Design:

Case series; Level of evidence, 4.

Methods:

Data were prospectively collected and retrospectively reviewed for all patients who underwent an all-arthroscopic biceps tenodesis during concomitant double-row RCR by the senior author between January 2014 and May 2018. Patients were included if they underwent this procedure and had baseline preoperative patient-reported outcomes (PROs) with a minimum of 1 year of postoperative PROs for the American Shoulder and Elbow Surgeons (ASES) score and visual analog scale (VAS) for pain score. Additionally, patient data, surgical history, postoperative complications, and satisfaction were reported.

Results:

Fifteen patients were eligible for the study. There were 12 (80%) men and 3 (20%) women with a mean age of 50.0 years (range, 35-64 years). The mean follow-up time was 25.2 months (range, 13-63 months). Six of 15 (40%) patients also had an arthroscopic subscapularis repair performed. ASES shoulder scores improved from 37.1 preoperatively to 94.1 postoperatively (P < .001), and VAS scores improved from 6.4 preoperatively to 0.5 postoperatively (P < .001). One patient who underwent concomitant subscapularis repair reported continued anterior groove pain. No patients experienced biceps cramping, developed a deformity, or required a repeat operation at the final follow-up. Overall, 93.3% of the patients reported being highly satisfied with their surgery.

Conclusion:

This study presents the clinical results of an all-arthroscopic technique for concomitant double-row RCR and biceps tenodesis, which resulted in high rates of patient satisfaction and significant improvement in reported shoulder outcome and pain scores. Additionally, this technique offers the potential benefits of avoiding a secondary incision, which may decrease surgical morbidity while also decreasing cost by eliminating the need for an extra, tenodesis-specific implant.

The Loop 'n' Tack Knot: Biomechanical Analysis of a Novel Suture Technique for Proximal Biceps Tenodesis

Background

Secure tendon grasping is critical to the success of any tenodesis procedure. Several techniques currently used for tendon grasping can result in longitudinal splitting of the tendon, causing construct failure and failure of the tenodesis.

Purpose

To compare the Loop 'n' Tack knot as a tendon-grasping technique with other common suture techniques. We investigated the biomechanical strength and mode of failure.

Study Design

Controlled laboratory study.

Methods

Eleven matched pairs of proximal biceps were harvested from fresh-frozen cadaveric shoulders. One tendon from each pair was stitched using 1 of 4 different techniques. The suture techniques evaluated included the Loop 'n' Tack with 2 different types of high-strength nonabsorbable suture, a double half-racking stitch, and a Krakow stitch. Samples were cyclically loaded between 5 and 20 N for 100 cycles, followed by a pull to failure at 33 mm/s.

Results

The Loop 'n' Tack techniques were equivalent to the double half-racking and Krakow techniques for load to ultimate failure (P = .817 and P = .984, respectively). The double half-racking technique was the stiffest construct, which was significantly greater than the second-stiffest group, the Loop 'n' Tack method with both FiberLink suture (P = .012) and SutureTape (P = .002), which had greater stiffness than the Krakow group (P < .001). The most common failure mode for the Loop 'n' Tack stitch was suture breakage compared with the Krakow and double half-racking methods, where the most common mode of failure was suture pullout from the tendon (P < .001).

Conclusion

Biomechanical testing found that the Loop 'n' Tack techniques had similar ultimate load to failure values when compared with the double half-racking and Krakow methods. Mode-of-failure analysis showed that the Loop 'n' Tack construct typically failed by suture breakage, whereas the other techniques failed by suture pullout.

Clinical Relevance

The Loop 'n' Tack technique allows for secure grasping of tissue without the need for externalization of the tendon. This technique may be beneficial in compromised or poor-quality tissue without reducing overall pullout strength when compared with a standard half-racking or Krakow stitch.

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.

Increased Risk of Humeral Fracture With Open Versus Arthroscopic Tenodesis of the Long Head of the Biceps Brachii

Purpose

To determine the risk of postoperative humeral fracture following tenotomy, open tenodesis and arthroscopic tenodesis of the long head of the biceps brachii.

Methods

A retrospective review of deidentified patient data from the Medicare Standard Analytic File using the PearlDiver software was conducted to identify procedures performed between 2005 and 2014. Groups were matched by age, gender, region, and medical comorbidities.

Results

We evaluated 157,163 patients who had undergone arthroscopic or open tenodesis or tenotomy of the long head of the biceps brachii over a 10-year period (2005-2014), and we identified 2,196 postoperative humeral fractures (1.4%). Matched subgroup analysis consisting of 44,292 patients demonstrated a statistically significant increase in humeral fracture risk in open (280; 1.26%) compared to arthroscopic tenodesis (232; 1.04%) with a P value of 0.03 and an odds ratio of 1.21. The majority of fractures were sustained by patients 65-74 years of age.

Conclusion

In this study, an increased risk of postoperative humeral fracture was associated with open tenodesis of the LHB.

Level of Evidence

III, Retrospective Comparative Trial.

The impact of workers' compensation on recovery after biceps tenodesis

BACKGROUND

There remains a paucity of studies examining the impact of workers' compensation (WC) on a variety of outcomes after biceps tenodesis. The purpose of this study was to compare the postoperative recovery curves after biceps tenodesis in patients with and without WC claims.

METHODS

Using the Surgical Outcomes System database, we assessed the postoperative recovery outcomes of all patients who had outcomes recorded at least 6 months after isolated biceps tenodesis for the treatment of a diagnosis of biceps tendinitis, stratified by WC status. The outcomes analyzed included visual analog scale, American Shoulder and Elbow Surgeons, VR-12 (Veterans RAND 12 Item Health Survey) mental and physical, Simple Shoulder Test, and Single Assessment Numeric Evaluation scores.

RESULTS

Overall, 139 patients with WC claims underwent isolated biceps tenodesis vs. 786 patients without WC claims. Demographic characteristics and comorbidities were similar in the 2 groups. Patients without WC claims had significantly improved visual analog scale, VR-12, American Shoulder and Elbow Surgeons, Single Assessment Numeric Evaluation, and Simple Shoulder Test scores at all times points after 3 months and 1 year compared with patients with WC claims.

CONCLUSIONS

On analysis of patients' recovery after isolated biceps tenodesis, WC claims led to significantly worse pain and functional outcomes at every time point of analysis (3, 6, 12, and 24 months). Furthermore, patients with WC claims had worse preoperative-to-postoperative improvements in most outcomes. This information can be used to educate surgeons and patients on postoperative expectations, as well as to perform analyses focused on health economics, value, and policy.

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.

Using Interconnected Knotless Anchor for Suprapectoral Biceps Tenodesis Could Offer Improved Biomechanical Properties in a Cadaveric Model

PURPOSE

To compare the biomechanical characteristics of the interconnected knotless anchor (IKA) fixation with the double knotless anchor (DKA) and interference screw (IS) fixation in the suprapectoral biceps tenodesis.

METHODS

In total, 24 fresh-frozen human cadaveric shoulders (mean age, 67.3 ± 6 years) were used for the study. All the specimens were randomly divided into 3 experimental biceps tenodesis groups (n = 8): IKA, DKA, and IS. After tenodesis, each specimen was preloaded at 5 N for 2 minutes, followed by a cyclic loading test from 5 to 70 N for 500 load cycles. Finally, a destructive axial load to failure test (1 mm/s) was performed. All the values, including ultimate failure load, stiffness, cyclic displacement, and mode of failure were evaluated.

RESULTS

The IKA provided the highest construct stiffness (38.9 ± 7.7 N/mm) and ultimate failure load (288.3 ± 47.6 N), the results for which were statistically better than the corresponding results in the IS and DKA groups. In terms of cyclic displacement, there were no statistical differences among the 3 fixation constructs. The most common failure mode was biceps tendon tearing in IS group (7/8) and IKA group (8/8). In the contrast, suture slippage accounted for the most common failure mode in DKA.

CONCLUSIONS

In suprapectoral bicep tenodesis, IKA fixation appears to offer improved construct stiffness and ultimate failure load while maintaining comparable suture slippage as compared with IS fixation or DKA fixation in the current biomechanical study.

CLINICAL RELEVANCE

The IKA fixation compares favorably with other techniques and could be an alternative clinical option for suprapectoral biceps tenodesis.

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.

Risk Factors for Postoperative Opioid Use in Arthroscopic Shoulder Labral Surgery

PURPOSE

To determine the correlation between preoperative and postoperative opioid use in patients undergoing arthroscopic shoulder labral repair, as well as patient risk factors associated with increased postoperative opioid use after the procedure.

METHODS

A retrospective review of all patients undergoing arthroscopic shoulder labral surgery at a single institution between August 2013 and November 2017 was performed. Patients were stratified as opioid nonusers, acute users, or chronic users based on preoperative consumption. Patient demographic characteristics, injury characteristics, surgical interventions, and postoperative opioid use for the first 12 months after surgery were then analyzed.

RESULTS

A total of 340 patients were included in this study. The average age was 26.3 years (range, 13-68 years), and the average body mass index was 27.5 (range, 18.4-45.0). Preoperative opioid users (acute and chronic) were found to continue to receive opioid medications at extended time points beyond 2 months postoperatively compared with nonusers (P < .001). Patients with intraoperatively identified SLAP tears experienced more preoperative pain and required more postoperative opioid prescriptions (P = .018). On stratification for other common shoulder instability injury patterns, no differences were found between the number of postoperative opioid prescriptions filled and the presence of Bankart lesion, Hill-Sachs lesion, reverse Hill-Sachs lesion, anterior labroligamentous periosteal sleeve avulsion, glenolabral articular disruption, or humeral avulsion of the glenohumeral ligament (P > .05).

CONCLUSIONS

In patients undergoing arthroscopic labral surgery, the chronicity of preoperative opioid use, number of concomitant procedures at the time of initial surgery, and presence of biceps tenodesis were found to significantly increase postoperative opioid demand. Orthopaedic surgeons should recognize risk factors for increased opioid use postoperatively and adapt treatment strategies and patient counseling accordingly.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Clinical relevance of the anatomy of the long head bicipital groove, an evidence-based review

Pathology in the bicipital groove can be a source of anterior shoulder pain. Many studies have compared treatment techniques for the long head biceps tendon (LHBT) without showing any clinically significant differences. As the LHBT is closely related to the bicipital groove, anatomical aspects of this groove could also be implicated in surgical outcomes. The aim of this review is to contribute to developing the optimal surgical treatment of LHBT pathology based on clinically relevant aspects of the bicipital groove. Medline/PubMed was systematically searched using key words "bicipital" and "groove" and combinations of their synonyms. Studies reporting on evolution, embryonic development, morphometry, vascularization, innervation, and surgical treatment of the LHBT and the bicipital groove were included. The length of the bicipital groove reported in the included studies ranged from 81.00 mm to 87.33 mm, width from 7.74 mm to 11.60 mm, and depth from 3.70 mm to 6.00 mm. The anatomy of the bicipital groove shows a bottleneck narrowing approximately two-thirds from superior. The transverse humeral ligament can constrain the bicipital groove and could be involved in anterior shoulder pain. When either LHBT tenotomy or tenodesis is performed, routinely releasing the transverse ligament could decrease postoperative anterior shoulder pain, which has frequently been reported in the literature. To avoid the bottle neck narrowing, a location below the bicipital groove may be preferred for biceps tenodesis over a more proximal tenodesis site. Level of evidence: IV.