Isolated Arthroscopic Biceps Tenotomy or Tenodesis Improves Symptoms in Patients with Massive Irreparable Rotator Cuff Tears

Raised Body Mass Index and Reduced Muscle Bulk Reduces The Incidence Of Popeye's Deformity Post Tenotomy Of Long Head of Biceps Brachii

OBJECTIVES

The development of the Popeye's deformity is a known complication of long head of bicep tendon (LHBT) tenotomy. Incidence of developing Popeye's deformity after LHBT tenotomy ranges between 13 - 70%. While this complication is well tolerated, it can be avoided with proper patient selection. We aim to study patient and clinical factors resulting in the development of the Popeye's deformity after LHBT tenotomy so as to better identify suitable surgical candidates.

METHODS

91 patients underwent unilateral rotator cuff repairs and concomitant LHBT tenotomy between March 2013 and March 2017. Assessment of patient factors contributing to Popeye's deformity included patient demographics and physical attributes were analysed and correlated. Patients also completed a questionnaire regarding their overall post-operative satisfaction. Prospectively collated Visual Analogue Pain (VAS), Constant-Murley Shoulder Score (CSS), UCLA Shoulder Score (UCLA) and Oxford Shoulder Score (OSS) were compared at 6 and 24 months post-operation between patients who developed Popeye's deformity and those who did not.

RESULTS

The incidence of post-tenotomy Popeye's sign was 58.9%. Majority of patients were satisfied with their procedure, postoperative function and cosmesis. Patients who developed Popeye's sign had a statistically significant lower body mass index (BMI) (24.9 ± 4.2 kg/m2 versus 27.3 ± 4.3 kg/m2, p = 0.048) (rpb = - 0.210, p > 0.05) and had a greater biceps circumference (in flexion) to wrist circumference ratio (1.91 ± 0.16 versus 1.83 ± 0.13, p = 0.012) (rpb = 0.319, p < 0.05) compared to those who did not. Nevertheless, the development of Popeye's sign did not affect clinical outcomes (VAS, CSS, UCLA and OSS, p > 0.05) at 24 months.

CONCLUSIONS

The incidence of Popeye's deformity is high post LHBT tenotomy. There was a greater incidence in patients with lower BMI and greater biceps brachii muscle bulk. However, this complication is well tolerated. By better selecting our patients, we can achieve better outcomes and minimise potential complications.

LEVEL OF EVIDENCE

Level III Evidence. Retrospective comparative study.

Pseudoparalysis and Pseudoparesis of the Shoulder: Definitions, Management, and Outcomes

Loss of shoulder function can be a complex condition to manage. Specifically, the definition between the terms pseudoparalysis and pseudoparesis remains inconsistent in the literature based on various factors including chronicity, present pathology, and the role of pain in the loss of function. There is also debate as to the optimal management strategies for these challenging conditions. In the setting of advanced glenohumeral arthritis or arthropathy in the correct patient, arthroplasty provides consistent and reliable results. However, in younger patients or the patient without arthritis, arthroplasty may not be the best option. In some cases, addressing pain with biceps procedures, balloon spacer placement, débridement, or others may be appropriate. However, other instances may require attempts at improving shoulder kinematics with procedures such as rotator cuff repair, superior capsular reconstruction, and tendon transfer. In this review, we discuss current definitions for pseudoparalysis and pseudoparesis, in addition to reviewing the indications for the various treatment options and their respective outcomes.

Arthroscopic Subacromial Balloon Spacer for Massive Rotator Cuff Tears Demonstrates Improved Shoulder Functionality and High Revision-Free Survival Rates at Minimum 5-Year Follow-up

PURPOSE

This study aimed to investigate the efficacy of arthroscopic subacromial balloon placement for massive rotator cuff tear (MRCT), assessing patient satisfaction, outcomes, shoulder functionality, pain scores, and revision-free survivorship up to eight years post the initial surgery.

METHODS

In this retrospective study with prospective data collection, patients with MRCTs undergoing balloon placement from 2014 to 2017 were prospectively enrolled. Their outcomes were analyzed retrospectively over a minimum 5-year follow-up. Demographics, patient satisfaction, reoperations, and complications were documented. Minimal clinically important differences (MCIDs) were calculated for SF-12 scores and Constant-Murley score (CMS) sub-scores. Pre- and post-surgery measures statistically compared for anatomical and functional evaluations.

RESULTS

In a study with 61 participants initially, 10 were lost to follow-up over 3 years. Of the remaining 51, 9 were lost at the latest follow-up. The cohort (42 participants, mean age 63.17 ± 7.66 years) was monitored for 83.98 ± 9.50 months. Seven participants required revisions within two years, resulting in an 83.33% revision-free survival rate. Significant improvements were observed from preoperative to latest follow-up: acromiohumeral interval decreased (7.83 to 6.56, p = 0.004), critical shoulder angle increased (36.10 to 38.24, p = 0.001), osteoarthritis grade increased (1.45 to 2.81, p = 0.001), SF-12 physical score improved (27.40 to 37.69, p = 0.001), and Constant-Murley total scores increased (26.50 to 68.69, p = 0.001). MCID for total Constant-Murley scores was 11.78 points. Among those without revisions, satisfaction rates were 11.43% excellent, 57.14% satisfied, and 31.43% dissatisfied.

CONCLUSIONS

Employing a balloon spacer for MRCTs yielded moderate satisfaction at the 5-year follow-up, with stable revision rates within the first 2 years. Notably, low revision surgery rates, high revision-free survival, and significant shoulder functionality improvements were observed at a minimum 5-year follow-up with arthroscopic subacromial balloon placement in conjunction with biceps tenotomy and subacromial bursectomy for MRCT.

Editorial Commentary: Tuberoplasty Is a Reliable Option to Address Pain in Massive Irreparable Rotator Cuff Tears

The massive irreparable rotator cuff tear remains a challenging condition for which there are many reported treatment options, including biceps tenotomy or tenodesis, subacromial decompression, cuff debridement, partial or augmented rotator cuff repair, bursal acromial reconstruction, balloon spacer placement, superior capsular reconstruction, reverse total shoulder arthroplasty, and tendon transfer, among others. Optimally treating the condition relies on paying attention to several patient factors, including correctly identifying whether function loss is driven by pain or compromised shoulder kinematics. If pain is the primary limiting factor, then tuberoplasty, or "reversed subacromial decompression," seems to be a reliable option that can afford encouraging results in terms of pain and range of motion in correctly indicated individuals. It is important to note, however, that these results should not be expected in the patient with anterior-superior humeral escape or pseudoparalysis, in whom a kinematic-restoring option may be more appropriate. Considering a history of inconsistent terminology and definitions when it comes to defining massive tears, when they are irreparable, and when the patient has pseudoparesis versus pseudoparalysis, it is paramount to accurately describe patient factors, including preoperative function, in ongoing research.

Reversing chronic pseudoparesis secondary to massive, irreparable rotator cuff tear: superior capsular reconstruction vs. reverse total shoulder arthroplasty

INTRODUCTION

Recent studies have defined pseudoparesis as limited active forward elevation between 45° and 90° and maintained passive range of motion (ROM) in the setting of a massive rotator cuff tear (RCT). Although pseudoparesis can be reliably reversed with reverse total shoulder arthroplasty (RSA) or superior capsular reconstruction (SCR), the optimal treatment for this indication remains unknown. The purpose of this study was to compare the clinical outcomes of RSA to SCR in patients with pseudoparesis secondary to massive, irreparable RCT (miRCT).

METHODS

This was a retrospective cohort study of consecutive patients aged 40-70 years with pseudoparesis secondary to miRCT who were treated with either RSA or SCR by a single fellowship-trained shoulder surgeon from 2016 to 2021 with a minimum 12-month follow-up. Multivariate linear regression modeling was used to compare active ROM, visual analog pain scale (VAS), Subjective Shoulder Value (SSV), and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score between RSA and SCR while controlling for confounding variables.

RESULTS

Twenty-seven patients were included in the RSA cohort and 23 patients were included in the SCR cohort with similar mean follow-up times (26.2 ± 21.1 vs. 21.9 ± 14.7 months, respectively). The patients in the RSA group were significantly older than those in the SCR group (65.2 ± 4.4 vs. 54.2 ± 7.8 years, P < .001) and had more severe arthritis (1.8 ± 0.9 vs. 1.2 ± 0.5 Samilson-Prieto, P = .019). The pseudoparesis reversal rate among the RSA and SCR cohorts was 96.3% and 91.3%, respectively. On univariate analysis, the RSA cohort demonstrated significantly greater mean improvement in active FF (89° ± 26° vs. 73° ± 30° change, P = .048), greater postoperative SSV (91 ± 8% vs. 69 ± 25%, P < .001), lower postoperative VAS pain scores (0.6 ± 1.2 vs. 2.2 ± 2.9, P = .020), and less postoperative internal rotation (IR; 4.6° ± 1.6° vs. 6.9° ± 1.8°, P = .004) compared with SCR. On multivariate analysis controlling for age and osteoarthritis, RSA remained a significant predictor of greater SSV (β = 21.5, P = .021) and lower VAS scores (β = -1.4, P = .037), whereas SCR was predictive of greater IR ROM (β = 3.0, P = .043).

CONCLUSION

Although both RSA and SCR effectively reverse pseudoparesis, patients with RSA have higher SSV and lower pain scores but less IR after controlling for age and osteoarthritis. The results of this study may inform surgical decision making for patients who are suitable candidates for either procedure.

Novel all-arthroscopic biceps tenodesis technique incorporated into rotator cuff repair-two hundred cases with minimum 2-year follow-up

Background

Biceps tendon pathology is a common source of pain in the shoulder. It is frequently seen in conjunction with symptomatic rotator cuff tears. Biceps tendon management during arthroscopic rotator cuff repairs can be achieved via tenodesis with various techniques or tenotomy. Tenodesis of the biceps generally results in less deformity and reduced exertion-related cramping. However, most techniques require the addition of some type of hardware to provide fixation for the biceps tendon, which adds cost, time, and complexity. This study presents a technique for an all-arthroscopic bicep tenodesis performed in conjunction with a double-row rotator cuff repair, requiring no additional hardware.

Methods

This study is a retrospective review of data that were prospectively collected for 200 consecutive patients for whom the procedure was performed. Patients were seen postoperatively at 2 weeks, 6 weeks, 4 months, and 6 months and in addition massive rotator cuff repairs were seen at 8 months. Additionally all patients were contacted at a minimum 2-year follow-up to access for the presence deformity, the American Shoulder and Elbow Surgeons (ASES) score, and SANE score. Descriptive statistics and comparisons to known minimal clinical important differences (MCIDs) for the patient recorded outcome measures were recorded.

Results

Two hundred patients were included in the study and 152 responded to the telephone interviews. The mean age of the patients at the time of surgery was 65.3 year old (standard deviation ± 9.1, range of 46-84), and the mean postoperative phone interview was 3.2 years postsurgery (standard deviation of ± 1.0, range of 2-5 years). The average ASES score improved from 52.6 to 94.6, which is 3 times greater than the minimal clinical important difference. The average postoperative SANE score was 94. Seven procedures out of the 200 were labeled as failures due to 1 patient's nonsatisfaction with the procedure and 3 for a Popeye deformity and 3 that had a revision RCR.

Discussion

The described method of an arthroscopic biceps tenodesis performed with a rotator cuff repair uses no extra hardware, requires minimal additional operative time, and is clinically effective. At a minimum 2-year follow-up, the all-arthroscopic biceps tenodesis in conjunction with a double-row rotator cuff repair resulted in a marked improvement in their ASES score with a 3.5% failure rate.

Conclusion

The all-arthroscopic bicep tenodesis performed in conjunction with a double-row rotator cuff repair demonstrated improved clinical outcome, without requiring any additional hardware to tenodese the biceps, at a minimum 2-year follow-up.

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

Background

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

Purpose

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

Study Design

Case series; Level of evidence, 4.

Methods

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

Results

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

Conclusion

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

Latin American formal consensus on the indications for the surgical treatment of massive and irreparable rotator cuff tears

OBJECTIVES

To implement the Formal Consensus Method among a group of experts in shoulder surgery in Latin America, in order to establish appropriate indications for the surgical treatment of massive and irreparable rotator cuff injuries.

METHODS

The Formal Consensus Method was used to develop surgical treatment recommendations for massive and irreparable rotator cuff tears (MIRCT). Three independent groups of experts in shoulder surgery were confirmed. The steering group conducted a systematic literature review and constructed a voting matrix consisting of 348 clinical scenarios. The rating group, composed of 15 members, rated each scenario on two occasions: first anonymously and then during an in-person discussion meeting. The median and voting ranges were used to classify each scenario as inappropriate, uncertain, or appropriate for each surgical technique. Finally, the reading group, consisting of 10 surgeons, reviewed, evaluated and rated the recommendations derived from the detailed analysis of the voting grids.

RESULTS

The main finding of the study reveals a high percentage (70%) of clinical scenarios in which consensus was achieved regarding the appropriateness or inappropriateness of different surgical alternatives for the treatment of massive and irreparable rotator cuff injuries. Through a detailed analysis of the voting grids, a total of 20 recommendations were elaborated concerning the appropriateness of various surgical techniques in addressing irreparable rotator cuff tears.

CONCLUSIONS

The indications for the operative treatment of MIRCT were determined based on expert consensus and the best available evidence, they seek to provide guidance on the appropriateness of various surgical techniques for different clinical scenarios.

LEVEL OF EVIDENCE

V.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICAL RELEVANCE

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

Concomitant Biceps Tenodesis Does Not Compromise Arthroscopic Rotator Cuff Repair Outcomes

PURPOSE

To compare outcomes of patients who underwent rotator cuff repair (RCR) with concomitant biceps tenodesis with those who underwent an isolated RCR.

METHODS

Exclusion criteria included previous ipsilateral shoulder surgery, irreparable rotator cuff tears, rotator cuff arthropathy, calcific tendinitis, adhesive capsulitis requiring a capsular release, or advanced osteoarthritis of the glenohumeral joint. Patients were indicated for biceps tenodesis if they had any degree of tendon tearing, moderate-to-severe tenosynovitis, instability, or a significant degenerative SLAP tear. Primary outcome measures included American Shoulder and Elbow Surgeons score, Simple Shoulder Test, EuroQoL 5-Dimension 5-Level visual analog scale, EuroQoL 5-Dimension 5-Level, and a site-specific questionnaire, which focused on surgical expectations, satisfaction, and complications. Multivariate analysis of variance to analyze descriptive statistics and determine significant differences between the patient groups for subjective and objective outcome measures were performed.

RESULTS

There were no significant differences for pain/visual analog scale (0.34 ± 0.09 vs 0.47 ± 0.09, P = .31), American Shoulder and Elbow Surgeons score (96.69 ± 0.87 vs 94.44 ± 0.91, P = .07), and Simple Shoulder Test (11.42 ± 0.17 vs 10.95 ± 0.18, P = .06) between the RCR with concomitant biceps tenodesis and isolated RCR at a minimum of 2 years' postoperatively. This is despite the RCR with concomitant biceps tenodesis group having significantly larger rotator cuff tears (4.25 ± 0.30 cm2 vs 2.80 ± 0.32 cm2, P = .001) than the isolated RCR group.

CONCLUSIONS

This study revealed that concomitant biceps tenodesis does not compromise outcomes when compared with an isolated RCR at 2-year follow-up, despite this group having larger rotator cuff tears.

LEVEL OF EVIDENCE

Level III, retrospective case study.

Top 50 most impactful publications on massive rotator cuff tears

Background

Bibliometric analysis is a useful tool for measuring the scholarly impact of a topic and its more and less heavily studied aspects. The purpose of this study is to use bibliometric analysis to comprehensively analyze the 50 articles with the highest citation indices in studies evaluating the treatment and outcomes of massive rotator cuff tears (mRCTs).

Methods

This cross-sectional study identified articles within the Scopus database published through December 2022. Keywords used were "massive rotator cuff tear." Articles were sorted in chronological order. The year published and number of citations were recorded. A citation index (CI) was calculated for each article by dividing the number of citations by number of years published [1 citation/1 year published (2021) = CI of 1]. Of these, the 50 articles with the highest CIs were carried forward for evaluation. Frequencies and distributions were assessed for data of each variable collected.

Results

These search methods produced 625 articles regarding mRCT research (ranging from January 1986 to December 2022). Four of the top 10 most impactful articles were published in the 2010s. The level of evidence (LOE) published with the greatest frequency was level of evidence 4 (41%). The journal Arthroscopy published the highest number within the top 50 (26%) followed by the Journal of Bone and Joint Surgery and the American Journal of Sports Medicine (20% each). Clinical studies composed 88% of the top 50. Case series (38%) predominated, while systematic reviews (20%) and randomized control trials (8%) were less prevalent. The majority of studies concentrated on the clinical outcomes of certain interventions (62%), mainly comparing multiple interventions.

Conclusion

Despite the relatively high prevalence of mRCTs (40% of all tears), this topic comprises only a small proportion of all rotator cuff research. This analysis has identified gaps within and limitations of the findings concerning mRCTs for researchers to propose research questions targeting understudied topics and influence the future treatment and outcomes of this clinically difficult diagnosis.

Subacromial Balloon Spacer Implantation Is a Promising Alternative for Patients With Massive Irreparable Rotator Cuff Tears: A Systematic Review

PURPOSE

To provide an overview of the existing literature on subacromial balloon spacers for the treatment of massive irreparable rotator cuff tears, in an effort to inform surgeons of the procedure's clinical effectiveness.

METHODS

The PubMed, Scopus, and Ovid EMBASE databases were queried to identify studies evaluating the clinical, radiographic, and patient-reported outcomes of patients indicated for subacromial balloon spacer implantation. The following datapoints were extracted: study demographics, patient baseline characteristics, and postoperative outcomes of interest. Outcomes were evaluated at baseline and at the longest available follow-up period.

RESULTS

A total 766 patients were included among 22 included studies, with an average follow-up of 27.54 months. Improvements were seen for all clinical and patient-reported outcomes: forward elevation (ranging from 9.20 to 90.00° improvement), external rotation (ranging from 2.00 to 22.00°), abduction (ranging from 14.00 to 95.00°), Total Constant Score (ranging from 7.70 to 50.00), American Shoulder and Elbow Surgeons score (ranging from 24.60 to 59.84), Oxford Shoulder Score (ranging from 7.20 to 22.20), and pain score (ranging from 3.57 to 6.50). Minimal differences were seen in acromiohumeral interval (ranging from -2.00 to 1.27). Reoperation and complication rates ranged from 0% to 33% and 0% to 19.64%, respectively.

CONCLUSIONS

The short-term results of subacromial balloon spacers for management of massive rotator cuff tears demonstrate clinically relevant improvements in shoulder range of motion and substantial improvements in patient-reported outcome measures. Of note, minimal change in acromiohumeral interval was seen on postoperative radiography, and wide variations in complication and reoperation rates were reported across studies.

LEVEL OF EVIDENCE

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

Methods of analyzing the long head of the biceps tendon in the management of distal supraspinatus tendon ruptures. Part 2: The role and validation of an arthroscopic exploration protocol of the long head of the biceps tendon

INTRODUCTION

Inter-observer arthroscopic assessments of the Long head of the Biceps tendon (LHB) injuries, in the absence of predefined instructions, are poorly reproducible. There are several types of LHB injuries, of varying severity, which can make its intraoperative analysis subjective.

HYPOTHESIS

The application of a precise arthroscopic exploration protocol, particularly dynamic, associated with an equally precise analysis of the possible tendon lesions, intrinsic or extrinsic, makes it possible to obtain a reproducible analysis of the lesions of the LHB and aid decision-making around its conservation or its resection, in distal supraspinatus tendon ruptures.

MATERIAL AND METHODS

This was a prospective, multicenter study including 371 patients with a stage 1 rupture of the supraspinatus tendon, in accordance with the Patte classification. An exploration protocol with intraoperative video recording of the articular portion of the biceps was systematically performed by the operators. It included static intra-articular and extra-articular observation of the LHB, as well as a dynamic intra-articular hook test with mobilization in internal and external rotation, and in anterior elevation. An analysis of the lesion status of the LHB was then made by the principal operator (Op), after defining the various possible lesions: intrinsic or extrinsic. This initial diagnostic assessment was then compared with the analysis made by two independent observers (Obs1, Obs2) based on a replay of the recorded videos. The reliability of agreement was then measured using Cohen's Kappa coefficient (K) and Fleiss' kappa.

RESULTS

Two hundred and fifty-seven videos were analyzable. The level of agreement between the two independent observers was strong (K=0.63) for applying the diagnosis of a healthy or pathological biceps. The agreement between the independent observers and the operator was weaker (respectively K Op-Obs1=0.51 - moderate and K Op-Obs2=0.39 - poor).

CONCLUSION

The application of a precise protocol for the exploration of the LHB, associated with a previously defined lesion classification, makes it possible to obtain a high rate of agreement for the arthroscopic diagnostic analysis of the LHB. However, arthroscopy cannot be used as the only criterion for deciding which procedure to perform on the LHB. Other clinical and para-clinical factors must be taken into consideration.

LEVEL OF EVIDENCE

III; prospective inter-observer series.

Arthroscopic advancement of the supraspinatus muscle and tendon for posterosuperior massive rotator cuff tears

The tension-free repair of retracted supraspinatus tears with the open muscle and tendon advancement technique first described by Debeyre in 1965 gave satisfactory clinical results. The purpose of this anatomical study was to test the feasibility of an arthroscopic supraspinatus advancement technique. A total of 10 cadaveric shoulders were operated. We assessed the feasibility, measured the slide distance, and recorded the position of the suprascapular nerve (SSN) for each shoulder. Reattachment of the tendon to its native footprint was achieved in all cases. The mean slide distance was 38.8 mm ± 3.6 (33-44). The SSN was released and tension-free in all shoulders. Arthroscopic advancement of the supraspinatus muscle and tendon enables complete rotator cuff repair in irreparable retracted posterosuperior tears and is a noteworthy alternative to the other techniques. Level of Evidence: IV.

Outcomes of subacromial balloon spacer implantation for irreparable rotator cuff tears: a systematic review and meta-analysis

BACKGROUND

The management of irreparable rotator cuff tears remains a topic of considerable debate among orthopedic surgeons. Currently, there is little consensus regarding the gold-standard treatment; however, an emerging option involves the use of a biodegradable subacromial spacer. The purpose of this study, therefore, was to systematically review and synthesize the current literature reporting on the clinical outcomes following implantation of a subacromial balloon spacer (SABS) for the treatment of patients with irreparable rotator cuff tears.

METHODS

A systematic review of the PubMed Central, MEDLINE, Embase, Scopus, and Cochrane Library databases from inception through December 2022 was performed. Clinical outcome studies reporting on functional and clinical outcomes, as well as postoperative complications, were included.

RESULTS

A total of 127 studies were initially identified, of which 28 were deemed eligible for inclusion in our review. Of these studies, 17 reported adequate preoperative and postoperative data (mean and a measure of variance) and thus were included in the meta-analysis. Among the included studies, a total of 894 shoulders (886 patients) were included; the mean age was 67.4 years (range, 61.7-76.2 years). The average follow-up period was 30.4 months (range, 12-56 months). All postoperative patient-reported outcomes improved significantly from baseline, including the Constant score (mean difference, 33.53; P < .001), American Shoulder and Elbow Surgeons score (mean difference, 40.38; P < .001), Oxford Shoulder Score (mean difference, 12.05; P = .004), and visual analog scale pain score or Numeric Pain Rating Scale score (mean difference, -3.79; P < .001). Forward elevation (mean difference, 24°; P < .001), abduction (mean difference, 52°; P = .02), and external rotation (mean difference, 15°; P < .001) improved. Device-related complications occurred at a rate of 3.6%, the most common of which were balloon migration (1.0%) and synovitis (0.6%). Ultimately, 5% of patients required salvage reverse shoulder arthroplasty.

CONCLUSION

Short-term outcomes suggest that SABS implantation can be a safe and effective treatment and appears to be associated with early improvements in postoperative pain and function. Clinical heterogeneity, use of concomitant procedures, and variations in patient selection limit our ability to conclusively interpret the available evidence. We do not yet know the potential therapeutic value of SABS implantation relative to other currently accepted treatment strategies, the length of symptomatic improvement that can be expected, or the long-term implications of SABS use on the outcomes of further salvage procedures.

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.

Minimal inter-surgeon agreement on the diagnosis of pseudoparalysis in patients with massive rotator cuff tears

BACKGROUND

Pseudoparalysis is commonly used to describe patients with severe loss of active elevation associated with advanced rotator cuff disease, but its definition in the literature has been variable. This study aimed to determine how 15 expert shoulder surgeons use the term "pseudoparalysis" when presented with clinical cases and assess clinical agreement on the diagnosis of pseudoparalysis.

METHODS

Fifteen expert shoulder surgeons were surveyed regarding 18 patients with magnetic resonance imaging-diagnosed massive rotator cuff tears, restricted active range of motion (ROM), full passive ROM, and without advanced rotator cuff arthropathy (Hamada grade <3). The survey included 18 patient vignettes with key clinical details and a deidentified video demonstrating the physical examination of the patient. For all patients, surgeons were instructed to assume that the patient has a full passive ROM. An anteroposterior radiograph and T2 sequences of the patient's coronal, axial, and sagittal magnetic resonance imaging were also provided. After each case, the surgeons were asked: (1) does the patient have pseudoparalysis, and (2) if so, how severe it is. At the end of the patient vignettes, surgeons were asked to define pseudoparalysis using a checklist with predefined options. Surgeons were also asked if there was a difference between the term pseudoparalysis and pseudoparesis. Fleiss' kappa (κ) correlation coefficient was used to determine intersurgeon agreement.

RESULTS

There was minimal inter-rater agreement on the diagnosis of pseudoparalysis (κ = 0.360) and no agreement on describing the severity of pseudoparalysis (κ = -0.057). Although 80% of surgeons stated that an active glenohumeral elevation less than 90° was a diagnostic feature of pseudoparalysis, there was disagreement on the remaining criteria, leading to no agreement on a set of universal criteria that defines pseudoparalysis. A total of 67% included maintained full passive elevation, 33% included the absence of pain, 67% included elevation causing anterosuperior escape, and 27% included an additional unlisted factor. There was minimal agreement among the 15 surgeons on the diagnostic criteria of pseudoparalysis (κ = 0.092). Finally, 7 surgeons stated that pseudoparalysis and pseudoparesis are identical, whereas 8 surgeons stated that they are 2 different clinical diagnoses.

CONCLUSION

Among this panel of expert shoulder surgeons, there was a lack of consensus on the definition of pseudoparalysis and minimal agreement on the diagnosis of pseudoparalysis based on clinical scenarios. In addition, half the surgeons believed that pseudoparalysis and pseudoparesis are identical, whereas the other half believed that they represent 2 separate clinical entities. A standardized definition of pseudoparalysis would be of value to facilitate communication and research efforts.

Subacromial balloon spacers for the treatment of irreparable rotator cuff tears: a review

Massive irreparable rotator cuff tears (RCTs) are a commonly encountered orthopedic condition that can be difficult to treat. Several techniques have been described to manage these tears, with the implantable subacromial balloon spacer being one of the most recent. The device, which has only been approved for clinical use in the United States since 2021, functions by resisting the superior humeral head migration seen in the setting of massive RCTs and restoring normal shoulder biomechanics, as corroborated by cadaveric studies. However, results regarding clinical outcomes have been mixed to date, and further high-quality studies are needed to define the optimal use of the subacromial balloon spacer in the treatment of massive irreparable RCTs.

Comparison of Outcomes After Arthroscopic Superior Capsule Reconstruction Versus Arthroscopic Partial Repair or Arthroscopic Debridement for Irreparable Rotator Cuff Tears

Background

Arthroscopic superior capsule reconstruction (SCR), arthroscopic partial repair (PR), and arthroscopic debridement (DB) are valid treatment options for irreparable rotator cuff (RC) tears.

Purpose/Hypothesis

The purpose of this study was to compare clinical, functional, and radiological outcomes of arthroscopic SCR with arthroscopic PR and arthroscopic DB in patients with irreparable posterosuperior RC tears. It was hypothesized that SCR would lead to superior clinical and functional outcomes compared with PR or DB.

Study Design

Cohort study; Level of evidence, 3.

Methods

Clinical and functional outcomes of this single-center retrospective study included range of motion, strength, and the age- and sex-adjusted Constant-Murley score. Patient-reported outcome measures (PROMs) involved the quick Disabilities of the Arm, Shoulder and Hand score, the Subjective Shoulder Value, and the visual analog scale for pain. Graft and repaired tendon integrity was evaluated by magnetic resonance imaging (MRI) at 12 months of follow-up.

Results

In total, 57 patients treated with SCR (n = 20), PR (n = 17), and DB (n = 20) were included. The mean clinical follow-up was 33.8 ± 17.9 months. Preoperative clinical and functional characteristics were comparable among the 3 groups. The range of motion and clinical and functional scores of all 3 groups significantly improved from pre- to postoperatively. Postoperative PROMs showed no differences among all 3 study groups. SCR revealed significantly higher postoperative strength compared with PR (P = .001) and DB (P = .004). Postoperative MRI revealed a rerupture in 4 patients with SCR (20%). Postoperative MRI showed a rerupture in 9 patients with PR ( 53%). Fatty muscle infiltration of the supraspinatus and infraspinatus significantly progressed within all 3 study groups in postoperative MRI scans. No clinical and functional differences were observed between intact and reruptured PR.

Conclusion

Patients who underwent SCR had better postoperative strength recovery than patients who underwent PR or DB.

Massive and Irreparable Rotator Cuff Tears: A Review of Current Definitions and Concepts

Background

While massive and irreparable rotator cuff tears (MIRCTs) have been abundantly studied, inconsistent definitions in the literature and theories about pain and dysfunction related to them can be difficult to navigate when considering an individual patient.

Purpose

To review the current literature for definitions and critical concepts that drive decision-making for MIRCTs.

Study Design

Narrative review.

Methods

A search of the PubMed database was performed to conduct a comprehensive literature review on MIRCTs. A total of 97 studies were included.

Results

Recent literature reflects added attention to clarifying the definitions of "massive, "irreparable," and "pseudoparalysis." In addition, numerous recent studies have added to the understanding of what generates pain and dysfunction from this condition and have reported on new techniques for addressing them.

Conclusion

The current literature provides a nuanced set of definitions and conceptual foundations on MIRCTs. These can be used to better define these complex conditions in patients when comparing current surgical techniques to address MIRCTs, as well as when interpreting the results of new techniques. While the number of effective treatment options has increased, high-quality and comparative evidence on treatments for MIRCTs is lacking.

Arthroscopic approach does not yield better results than open surgery after subscapularis repair: a systematic review

PURPOSE

This study aimed to compare the long-term outcomes of arthroscopic versus mini-open repair in patients with isolated subscapularis tendon tears.

METHODS

Google Scholar, PubMed, and Embase databases were searched for studies evaluating isolated subscapularis tears subsequently treated by arthroscopic or mini-open repair. The inclusion criteria were clinical studies reporting isolated subscapularis lesions treated by arthroscopic or mini-open repair, a minimum follow-up of 12 months, and clinical and functional outcomes reported in the study results. Articles not reporting functional outcomes or studies that reported results for anterosuperior rotator cuff tears without a separate analysis of subscapularis tendon tears were excluded. Studies older than 20 years and studies with a minimum follow-up of less than 12 months were also excluded.

RESULTS

A total of 12 studies met the inclusion criteria; 8 papers were included in the arthroscopic repair group, and 6 were included in the mini-open repair group (2 studies reported results for both techniques). The mean age reported was 49.3 years, and 85.1% of patients were male. The dominant limb was involved in 77.6% of the patients, and a traumatic onset of symptoms was verified in 76.3%. The mean time to surgery was 9.6 months. The Constant-Murley score showed positive results for the arthroscopic and mini-open groups, with mean postoperative values of 84.6 and 82.1, respectively. Promising results were also observed for pain, with a mean of 13.2 (out of 15) points for the arthroscopic group and 11.7 for the mini-open group. The long head of the biceps was involved in 78% of the patients, and LHB tenodesis or tenotomy were the most common concomitant procedures performed.

CONCLUSIONS

There was no significant difference in clinical and functional outcomes between open and arthroscopic repair. Moreover, the same complication rates were reported in both treatments, but arthroscopic repair led to less postoperative pain.

LEVEL OF EVIDENCE

IV.

Outcomes of Isolated Biceps Tenodesis/Tenotomy or Partial Rotator Cuff Repair Associated with Biceps Tenodesis/Tenotomy for Massive Irreparable Tears: A Systematic Review

Irreparable large to massive rotator cuff tears (MIRCTs) are a prevalent cause of shoulder pain and dysfunction, and nonoperative treatment may not always be effective. Various surgical options exist, with isolated biceps tenotomy/tenodesis (BT) or arthroscopic partial repair with associated biceps tenotomy/tenodesis (PCR-BT) being the most common. The aim of this study was to systematically review the available data on the clinical and functional outcomes of BT and PCR-BT in patients with MIRCTs.

METHODS

MEDLINE, Embase, and CENTRAL databases were searched for studies on the treatment of MIRCT. We included studies with BT or PCR-BT with a minimum follow-up of 24 months. The MINORS (Methodological Index for Nonrandomized Studies) score was used to assess study quality. Outcomes included were the visual analog scale for pain, functional scores such as Constant-Murley and American Shoulder and Elbow Surgeons, range of motion, radiological measurements, and complications.

RESULTS

A total of 1101 patients (506 had a BT and 595 had a PCR-BT) from 22 studies were included (cases series = 13, case-control = 7, randomized control trial = 1, prospective cohort study = 1). The mean MINORS score was 13.2 ± 3.2. The mean age and follow-up were 67 ± 6.8 years and 4.58 ± 1.1 years (range, 2, 12), respectively. The VAS improvement showed at the last follow-up for PCR-BT (range, 1.97, 5.8) and BT (range, 4, 6.1). CMS was improved at the final follow-up for PCR-BT (range, 13, 47.6) and BT (range, 10.8, 28). Regarding the ASES, it has demonstrated significant improvements for PCR-BT (range, 31.81, 44.8) and BT (range, 30,45.8). For forward flexion, PCR-BT showed improvement (range, -14°, 59.4°), as well as the BT group (range, 2°, 27.9°).

CONCLUSIONS

This systematic review demonstrated that both BT and PCR-BT improve functional outcomes and reduce pain at midterm follow-up for MIRCT. Since we know that a failed cuff repair would worsen the shoulder, it might be beneficial in terms of the risk-benefit ratio to not repair in certain patients with MIRCT.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

PRE-REGISTRATION

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

Nonoperative Treatment of the Biceps-Labral Complex

The long head of the biceps and superior labrum should be evaluated as an interdependent functional unit. A focused patient history and physical examination including multiple provocative tests should be performed alongside advanced imaging studies to obtain an accurate diagnosis. Nonoperative treatment modalities including nonsteroidal anti-inflammatory drugs, glucocorticoid injections, and a standardized physical therapy regimen should be exhausted before operative intervention. Significant improvements in pain, functional outcomes, and quality of life are achieved in patients treated nonoperatively. Although these outcomes are less consistent for overhead athletes, return to play and performance metrics seem comparable to those who undergo surgery.

Early postoperative recovery comparisons of superior capsule reconstruction to tendon transfers

BACKGROUND

The management of massive posterosuperior rotator cuff tears is controversial, with no gold standard. Two recently developed techniques that have shown promising initial results include arthroscopic superior capsular reconstruction (SCR) and tendon transfers (latissimus or lower trapezius). However, there remains a scarcity of studies examining each procedure's early postoperative clinical outcomes individually or in comparison to each other. The purpose of this study is to compare the early postoperative recovery outcomes of tendon transfers (TTs) to SCR.

METHODS

Using the surgical outcomes system global database (Arthrex Inc.), we assessed the postoperative recovery outcomes for all patients who had outcomes recorded at least 6 months after SCR or TT. The time points analyzed included preoperative and postoperative (2 weeks, 6 weeks, 3 months, 6 months, 1 year, 2 years). The outcomes analyzed included pain visual analog scale (VAS) score, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, VR-12 physical, and Single Assessment Numeric Evaluation (SANE).

RESULTS

Overall, 163 patients underwent SCR and 24 arthroscopically assisted TT. The mean age for SCR and TT was 60 and 56 years, respectively. Postoperative recovery curves demonstrate that both procedures produced improved outcomes at each postoperative time point compared to preoperative. The pain and functional outcomes measures, including VAS, ASES, SANE, and VR-12 physical, were comparable for TT and SCRs, with similar recovery curves between the 2 techniques. Ultimately at 2 years postoperatively, there were no significant differences between the 2 techniques.

CONCLUSIONS

Analysis of the early outcomes associated with arthroscopic treatment of massive posterosuperior rotator cuff tears demonstrated that the arthroscopically assisted tendon transfers and arthroscopic superior capsular reconstruction had similar pain and functional outcomes throughout the 2-year postoperative recovery period. Overall, the process of recovery appears equivalent between the 2 techniques. Future studies are needed to assess the outcomes of each technique and specific indications in an attempt to delineate an algorithm for the treatment of irreparable rotator cuff tears.

Superior capsule reconstruction, partial cuff repair, graft interposition, arthroscopic debridement or balloon spacers for large and massive irreparable rotator cuff tears: a systematic review and meta-analysis

BACKGROUND

Multiple non-arthroplasty surgical techniques are described for the management of large and massive irreparable rotator cuff tears. There is currently no consensus on the best management strategy. Our aim was to compare clinical outcomes following arthroscopic debridement, arthroscopic partial cuff repair, superior capsule reconstruction, balloon spacers or graft interposition for the management of large and massive irreparable rotator cuff tears.

METHODS

A comprehensive search was performed of the following databases: Medline, Embase, CINAHL and Cochrane Database of Systematic Reviews. Data were extracted from relevant studies published since January 2000 according to the pre-specified inclusion criteria. The primary outcome was the post-operative improvement in shoulder scores. Meta-analysis of the primary outcome was performed. Secondary outcomes included retear rates and complications.

RESULTS

Eighty-two studies were included reporting the outcomes of 2790 shoulders. Fifty-one studies were included in the meta-analysis of the primary outcome. The definition of an irreparable tear varied. All procedures resulted in improved shoulder scores at early follow-up. Shoulder scores declined after 2 years following balloon spacers, arthroscopic debridement and partial cuff repair. High retear rates were seen with partial cuff repairs (45%), graft interposition (21%) and superior capsule reconstruction (21%).

CONCLUSIONS

Large initial improvements in shoulder scores were demonstrated for all techniques despite high retear rates for reconstructive procedures. Shoulder scores may decline at mid- to long-term follow-up.

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.

Arthroscopic revision cuff repair: do tendons have a second chance to heal?

BACKGROUND

Few studies have investigated postoperative tendon integrity after reoperation for failed rotator cuff repair. The purpose of this study was to evaluate the anatomic and clinical outcomes of arthroscopic revision rotator cuff repair (AR-RCR) and identify the risk factors related to re-retear.

METHODS

Sixty-nine consecutive patients (mean age, 55 years) with primary failed open (38%) or arthroscopic (62%) cuff repairs underwent AR-RCR and were reviewed regarding clinical examination findings and imaging studies. Patients with massive cuff tears and upward humeral migration (acromiohumeral distance < 6 mm) or glenohumeral osteoarthritis were excluded. Revision repair was performed by a single, experienced shoulder surgeon. Complete footprint coverage was achieved in all cases using a single-row (70%), double-row (19%), or side-to-side (11%) technique. The primary outcome measure was tendon healing assessed with magnetic resonance imaging (57 cases) or computed tomography arthrogram (12 cases) performed at minimum 1-year follow-up. Secondary outcome measures included functional outcome scores, subjective results, and complications. The mean follow-up period was 43 months (range, 12-136 months).

RESULTS

The cuff tendons did not heal to the tuberosity in 36% of the shoulders (25 of 69) following revision cuff surgery. Absence of tendon healing was associated with poorer shoulder function (average Constant score, 69 ± 20 vs. 54 ± 18; P = .003) and a decreased Subjective Shoulder Value (72% vs. 54%, P = .002). Factors that were negatively associated with tendon healing were age ≥ 55 years (odds ratio [OR], 4.5 [95% confidence interval, 1.6-12.5]; P = .02), tendon retraction of stage 2 or higher (OR, 4.4 [95% confidence interval, 1.4-14.3]; P = .01), and fatty infiltration index > 2 (OR, 10.2; P < .0001). No differences in retear rates were found between single-row and double-row cases. In 36 shoulders, tissue samples were harvested and submitted for bacteriologic culture analysis; 13 (36%) showed positive findings for infection (Cutibacterium acnes in 12 of 13) and associated antibiotic treatment was given. Overall, 25% of patients had unsatisfactory clinical results and 22% were disappointed or dissatisfied. At last follow-up, 4 patients (5.7%) underwent reoperations, with a second AR-RCR in 1 and conversion to reverse shoulder arthroplasty in 3.

CONCLUSION

Despite careful patient selection and intraoperative complete footprint coverage, in this study the tendons did not heal to bone in 36% of cases after revision cuff surgery. The absence of tendon healing is associated with poorer clinical and subjective results. Patients aged ≥ 55 years and patients with larger tears (stage 2 or higher) and/or muscle fatty infiltration (fatty infiltration index > 2) have significantly lower rates of healing. Surgeons should be aware that structurally failed cuff repair may also be associated with low-grade infection.

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

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

METHODS

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

RESULTS

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

CONCLUSION

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

Is biceps tenodesis necessary when performing arthroscopic rotator cuff repair in patients older than 55 years?

INTRODUCTION

In patients with arthroscopic rotator cuff repair, tenotomy and tenodesis are the most performed surgical procedures for the biceps long head (BLH) pathologies. Controversy continues as to which surgical procedure provides better results. This study aimed to compare the clinical outcomes of tenotomy and tenodesis applied to the biceps long head in patients who underwent arthroscopic rotator cuff repair.

MATERIALS AND METHODS

In our study, the clinical results of 706 patients who underwent arthroscopic rotator cuff repair with tenotomy or tenodesis on the long biceps head were evaluated retrospectively. Rotator cuff repair patients were divided into two groups as single-row and double-row repair patients. The clinical results of patients who underwent tenotomy and tenodesis in single-row (n = 383) and double-row (n = 323) repair groups were compared. The clinical outcomes of the patients who underwent tenotomy and tenodesis without distinction between double/single-row repair were also compared. Preoperative and postoperative clinical evaluations of the patients were made with Constant Shoulder Score (CSS) and visual pain scale (VAS). The presence of the Popeye sign in the arm, tenderness in the bicipital groove, and cramping in the biceps muscle in the postoperative period was evaluated and compared among groups. Preoperative and postoperative clinical results of the patients were compared within the groups.

RESULTS

A total of 706 patients with a mean age of 61.78 ± 20.94 years and a mean follow-up period of 29.15 ± 14.28 months were evaluated. The mean age of the tenodesis group (58.13 ± 8.47) was significantly lower than the tenotomy group (61.52 ± 22.58) (p < 0.05). The mean CSS and VAS mean postoperatively in the tenotomy group (n = 587) were 76.84 ± 12.74 and 2.29 ± 2.78. The postoperative mean CSS and VAS in the tenodesis group (n = 119) were 77.56 ± 11.23 and 2.64 ± 2.70. There was no statistically significant difference between the postoperative clinical scores of patients who underwent tenotomy and patients who underwent tenodesis (p > 0.05). There was no difference between the tenotomy and tenodesis groups regarding Popeye deformity (p = 0.980). Bicipital groove tenderness and cramping in the biceps muscle were significantly higher in the tenodesis group (p < 0.001, < 0.001). Tenodesis was performed in 68, and tenotomy was performed in 315 out of 383 patients who underwent single-row rotator cuff repair. Tenodesis was performed in 51, and tenotomy was performed in 272 of 334 patients who underwent double-row rotator cuff repair. When singe versus double-row groups was compared, there was no significant difference in VAS, CSS, Popeye sing, bicipital groove tenderness, or biceps muscle cramping. When tenotomy versus tenodesis was compared within single- and double-row repair groups, there was no significant difference in VAS or CSS. There was no difference between the tenotomy and tenodesis groups regarding Popeye deformity, but bicipital groove tenderness and muscle cramping were more in tenodesis groups regardless of the repair rows.

CONCLUSIONS

The effect of tenodesis versus tenotomy for BHL pathologies in patients who underwent arthroscopic rotator cuff repair was not significant for clinical scores, but bicipital groove tenderness and biceps muscle cramping were significantly higher in the tenodesis group.

Complications of Long Head of the Biceps Tenotomy in Association with Arthroscopic Rotator Cuff Repair: Risk Factors and Influence on Outcomes

Background: This study aims to report the rate of biceps-related complications after LHB tenotomy, investigating related risk factors and their influence on the outcome. The hypothesis is that these complications have a limited clinical influence. Methods: A single-center prospective observational study was performed between 2015 and 2017 on consecutive patients who underwent RCR associated with LHB tenotomy. Patients were clinically and radiologically evaluated preoperatively, at six months and one year, and screened for postoperative popeye deformity, cramps, and bicipital discomfort. Each complication was analyzed for the following risk factors: age, sex, body mass index (BMI), dominant arm, manual work, tear patterns, and tendon healing. Finally, the clinical outcome was compared between patients with and without complications. Results: 207 patients were analyzed. Cramps, popeye deformity, and discomfort, were respectively, present in 16 (7.7%), 38 (18.4%) and 52 (25.1%) cases at six months and 17 (8.2%), 18 (8.7%) and 24 (11.6%) cases at one year. Cramps were associated with lower age (p = 0.0005), higher BMI (p = 0.0251), single tendon tear (p = 0.0168), manual work (p = 0.0086) at six months and manual work (p = 0.0345) at one year. Popeye deformity was associated with male sex at six months (p < 0.0001). Discomfort was associated with lower age (p = 0.0065), manual work (p = 0.0099), popeye deformity (p = 0.0240) at six months and manual work (p = 0.0200), single tendon tear (p = 0.0370), popeye deformity (p = 0.0033) at one year. Patients without complications showed a significant higher Constant score, pain and subjective shoulder value (SSV) (75.3 vs. 70.4, p = 0.00252; 0.9 vs. 1.9, p < 0.00001; 80.2 vs. 76.4; p = 0.00124) at six months and pain and SSV (0.6 vs. 2.0; p = 0.00044; 91.1 vs. 77.8; p ≤ 0.00001) at one year. Conclusions: Younger age, male sex, higher BMI, manual work, and single tendon tears are risk factors associated with the development of biceps-related symptoms during the first year after tenotomy in association with rotator cuff repair. Nevertheless, the clinical influence of these symptoms on shoulder outcomes is limited.

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.

Improvement in long head of biceps function and lower rate of biceps deformities after subpectoral tenodesis with cortical button and interference screw vs. arthroscopic tenotomy: a 4-year follow-up

Background

This study aimed to evaluate clinical, cosmetic, and strength midterm outcomes in arthroscopic biceps tenotomy and subpectoral biceps tenodesis using bicortical endobutton and interference screw.

Methods

In this retrospective study, inclusion criteria were long head of the biceps (LHB) pathologies treated either with tenotomy or an additional tenodesis. Postoperative assessment included Long Head of Biceps Score (LHBS), age-adjusted Constant-Murley Score, and Subjective Shoulder Value. Elbow flexion and forearm supination strength were measured. The presence of Popeye sign, cramps, and tenderness over the bicipital grove was evaluated. Statistical analysis of continuous variables without normal distribution was performed using Mann-Whitney U test. Grouped analysis was performed using 2-way analysis of variance. Binominal data were analyzed using chi-square test.

Results

A total of 73 patients with a mean age of 63.1 ± 9.6 years and a mean follow-up of 4.2 ± 0.5 years were included. Tenotomy was performed in 34 and tenodesis in 39 patients. Tenodesis group displayed a significantly higher LHB score (P = .0006), but no significant differences were detected for the age-adjusted Constant-Murley Score and Subjective Shoulder Value. Tenodesis group showed a significantly lower rate of Popeye deformities (P = .0007) and tenderness over the bicipital groove (P = .004). Patients from the tenotomy group with biceps deformity showed a significantly higher mean contralateral supination strength (P = .002) but no significant difference in contralateral elbow flexion compared with patients without biceps deformity. There was one (1.4%) complication in the tenotomy group (postoperative shoulder stiffness).

Conclusion

Both techniques resulted in comparable outcome scores on preselected patients, with tenodesis leading to better LHB function. Tenodesis did not improve elbow flexion and forearm supination strength beyond the tenotomy; however, it reduced the frequency of biceps deformities and tenderness over the bicipital groove. Patients with a strong contralateral forearm supination strength could be at risk of developing a biceps deformity after tenotomy.

Partial Rotator Cuff Repair Provides Improved Patient-Reported Outcome Measures Following Superior Capsule Reconstruction (SCR)

Purpose

To evaluate the role of concomitant partial rotator cuff repair (RCR) (i.e., infraspinatus) on patient-reported clinical outcomes following superior capsule reconstruction (SCR).

Methods

Postoperative recovery outcomes of SCR alone were compared with SCR with concomitant infraspinatus rotator cuff repair (SCR+RCR) at 3, 6, 12, and 24 months. Patients were included if they had an SCR surgery with or without a concomitant infraspinatus repair. Patients were excluded if they did not have a minimum of 6 months’ follow-up or if a preoperative baseline questionnaire was not performed. Outcome measures included pain visual analog scale, American Shoulder and Elbow Surgeons (ASES) Shoulder Function, ASES Shoulder Index, and Single Assessment Numeric Evaluation (SANE) score.

Results

Overall, 180 patients were evaluated, including 163 patients who underwent SCR alone and 17 patients who underwent concomitant infraspinatus repair (SCR+RCR). There was no difference in demographic data including age, sex, and body mass index. The postoperative recovery curves demonstrated SCR alone and SCR+RCR both provide significantly improved pain and functional scores at 2 years postoperatively (P < .001). When we compared the 2 groups, SCR+RCR provided significantly improved ASES Index (87.6 vs 78.2, P = .048) and ASES Function (25.5 vs 21.7, P = .02). There was no statistically significant difference in SANE scores (75.5 vs 64.2, P = .07) at 24 months’ follow-up.

Conclusions

SCR provides modest improvements in pain and function at 2 years postoperatively in patients with irreparable rotator cuff tears. Patients who underwent SCR and concomitant infraspinatus repair demonstrated significantly improved ASES Index and ASES Function scores and statistically nonsignificant improvement in SANE scores at 24 months postoperatively when compared with SCR alone.

Level of Evidence

III, retrospective cohort study.

Long head of the biceps intra-articular tenotomy using needle arthroscopy under local anesthesia: preliminary results and technical note

Purpose

Arthroscopic isolated biceps tenotomy is a procedure successfully performed in patients with degenerative rotator cuff tears which offers good clinical results. With this article, we describe the technique of biceps tenotomy with needle arthroscopy in local anesthesia and the results of first patients treated from 2018.

Methods

Thirteen patients with irreparable rotator cuff tear treated with arthroscopic needle biceps tenotomy under local anesthesia were included. Constant score and active/passive flexion were recorded preoperatively and at 3 months postoperatively.

Results

The average age of the patients was 71 ± 7 year old. All the patients were available for the follow-up. The Constant score significantly improved from pre- to postoperatively (44 ± 8.9 to 63.1 ± 14.2, p < 0.05). Active flexion improved from preoperatively 115 ± 24° to 145 ± 31° postoperatively (p < 0.05), while passive flexion did not significantly improve.

Conclusion

This technique can be safely performed in the elderly patient with irreparable rotator cuff tears and pain refractory to conservative measures.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40634-022-00508-5.

The subacromial spacer system for irreparable posterosuperior rotator cuff tears: A retrospective study of 47 patients with a two-year follow-up

BACKGROUND

Numerous surgical options are available for the management of massive irreparable rotator cuff tears, but there are no current definitive guidelines concerning the optimal treatment modality. The purpose of this study was to evaluate the efficacy and safety of a biodegradable subacromial spacer (InSpace) implantation in patients with irreparable rotator cuff tears.

METHODS

A retrospective study was conducted involving 47 patients treated with the InSpace balloon between 2016 and 2018. Shoulder function was assessed using Constant Score. Pain was scored using a visual analogue scale, with scores ranging from 0 to 10.

RESULTS

At an average follow-up of 24.6 months (range 12-38), the Constant Score had improved from 39.4 to 71.5 points (p < 0.0001). The range of motion, a main component of Constant Score, was improved after two years, from 27.6 to 42.2 points (p < .001). The visual analogue scale score decreased from 6.32 at baseline to a mean score of 2.7 points (p < 0.0001).

DISCUSSION

Arthroscopic deployment of the InSpace device was found to be a safe, reliable treatment option in patients with painful irreparable rotator cuff tears, with meaningful improvement in shoulder function without serious complications.

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.

Editorial Commentary: Shoulder Biceps Tenodesis Versus Tenotomy: Both Show Good Results and Have Different Indications

Shoulder long head biceps pathology is one of the most common causes of shoulder pain. The fact that there are many surgical techniques available has led to discussion of which should be the best treatment; although, in general terms, the two main options are tenotomy or tenodesis. Tenotomy is a simple technique, with a low rate of complications and a very good cost-benefit ratio, faster recovery, and less use of narcotic pain medications. Tenodesis has a lower risk of "Popeye deformity" and theoretically better biomechanics and strength, but few studies confirm superior outcomes in cases of biceps disease without concomitant lesions. In addition, there is no consensus as to which technique provides the best result: open or arthroscopic technique, subpectoral or fixation in the bicipital groove, soft tissue, or bony fixation. Generally, all techniques function at least two years after the surgery. We indicate arthroscopic suprapectoral bone tenodesis fixed with a screw in very selected cases: 20 patients <50 years old with good bone quality and engaged in work or sports that require flexion and supination strength. On the other hand, in chronic rupture with Popeye deformity and pain after rehabilitation, we perform open subpectoral tenodesis due to residual retraction, making suprapectoral fixation impossible or overtensioned. The correct length-tension of the long head biceps during tenodesis is critical; inappropriate tensioning can result in undesirable outcomes.

Arthroscopic Biceps Tenotomy Using a Single Portal for Working and Viewing: A Rabbit Model and Technique

Biceps tenotomy (BT) is a common surgery used to address anterior shoulder pain and joint dysfunction in humans. Using animal models to simulate human conditions is an effective and essential research strategy to further understand histologic and biomechanical processes that occur after BT, including the pathology of the detached biceps, secondary tendinopathic conditions of the rotator cuffs, and glenohumeral functional changes. This Technical Note presents a comprehensive step-by-step description of an arthroscopic BT procedure in rabbits. This technique is particularly beneficial, as the mini-invasive arthroscopic technique in a rabbit model is similar to that performed in humans. which resulted in less scarring and injuries to other adjacent structures in comparison with open surgery.

The IBTIS score; a new prognostic score for arthroscopic biceps tenotomies

INTRODUCTION

Shoulder pain associated with tendinopathy of the long head of biceps (LHB) is common. Surgical treatment with arthroscopic tenotomy of the LHB has been shown to be effective. However, it's efficacy is inconsistent. The objective of this study was to assess the pre-operative clinical and radiological prognostic factors of arthroscopic tenotomy of the long head of biceps, and to establish a predictive score for good responses to treatment; the IBTIS score (Isolated Biceps Tenotomy Index Score).

HYPOTHESIS

Prognostic factors representing a good response to treatment of LHB tendinopathy by arthroscopic tenotomy exist.

MATERIALS AND METHODS

We conducted a retrospective monocentric study including 64 patients who underwent surgery of the LHB by arthroscopic tenotomy (with or without tenodesis) between January 2018 and March 2020. We identified 2 patient groups (good responder group and poor responder group) from a 3-month post-operative clinical assessment, which included a subjective assessment comprising Single Shoulder Value (SSV), Constant score, C-Test, and pain level. Prognostic factors of a good response were then sought from the 2 groups using interviews, clinical examinations and pre-operative imaging. Based on these findings, a predictive score for a good response was established.

RESULTS

All evaluation criteria demonstrated post-operative improvement: mean SSV (72.2 vs 50.7; p<0.001), relative constant (78.2 vs 64.3; p<0.001), pain level (3.2 vs 7; p<0.001) and C-Test (94.1 vs 85.6; p=0.07). 34 patients (58.6%) were considered good responders, while 24 patients (41.38%) were considered poor responders. There was a trend towards a favourable result for: age>65 years (p=0.01), rotator cuff rupture on preoperative imaging (p=0.01), Cross Arm Test (p=0.02), nocturnal pain (p=0.08), Yergason's test (p=0.16) and Speed's Test (p=0.22). Manual labour appeared to be an unfavourable factor (p=0.07). These factors were incorporated into the 10-point IBTIS score. A score greater than 5 was associated with a favourable result in more than 80% of patients (p<0.001).

DISCUSSION

Our score consists of 7 items. We identified 7 pre-operative prognostic factors for a good result after LHB tenotomy. Over 65 years of age was found to be statistically significant in univariate analysis, as was visualization of rotator cuff rupture on pre-operative imaging. The Cross Arm Test was included given its high statistical significance. The Speed's Test and Yergason's Test are ubiquitous in the literature. Nocturnal pain was found in more than 80% of patients. Undertaking manual labour represented an unfavourable prognostic factor after arthroscopic surgery of the LHB.

CONCLUSION

The IBTIS score (Isolated Biceps Tenotomy Index Score) is a pre-operative clinico-radiological score for the surgical treatment of arthroscopic tenotomy of the long head of biceps. Further studies are required to validate its prognostic accuracy.

LEVEL OF EVIDENCE

III; case-control.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level IV.

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.

Quantitative magnetic resonance imaging assessment of the infraspinatus and teres minor in massive rotator cuff tear and its significance in clinical outcome after rotator cuff repair

BACKGROUND

Teres minor (TM) muscle hypertrophy in large to massive rotator cuff tears (RCTs) has been considered a compensatory change to atrophy of the infraspinatus (ISP). However, few reports have assessed its relation to the prognosis after rotator cuff repair.

METHODS

A total of 139 patients who underwent arthroscopic repair of large to massive RCTs involving the ISP between January 2013 and December 2015 were retrospectively investigated. Occupational ratios of the ISP (OR_ISP) and TM (OR_TM) were measured by sagittal magnetic resonance imaging (MRI). Rotator cuff healing was evaluated by MRI 1 year postoperatively, and functional outcomes using the Simple Shoulder Test (SST) and Constant score and external rotator (ER) strength by isokinetic muscle performance test (IMPT) were measured.

RESULTS

A total of 116 patients completed the MRI and IMPT at 1 year postoperatively, and functional scores were measured at least 2 years postoperatively. Of these, the repaired tendon had not healed in 34 patients (29%). There was a highly negative correlation between OR_ISP and OR_TM both pre- and postoperatively (Pearson correlation = -0.52 and -0.54, respectively). Preoperative OR_ISP was significantly higher in the healed than in the healing failure group (0.47 ± 0.10 vs. 0.41 ± 0.12, P = .02); however, postoperative OR_ISP and pre- and postoperative OR_TM were not. The preoperative OR_ISP cutoff value for healing was 0.46. For functional outcomes, only postoperative OR_ISP showed a statistical correlation with SST, Constant score (P = .04 and .03, respectively), and ER strength (P = .02).

CONCLUSION

TM muscle hypertrophy in large to massive RCT appears to be a compensatory change in the progression of atrophy of the ISP muscle and was not a significant indicator of either better healing of the repaired rotator cuff tendon or better function. Only preoperative OR_ISP was an independent prognostic factor affecting rotator cuff healing after repair of large to massive RCTs.

Biceps tenotomy or tenodesis in association with rotator cuff repair: is there an influence on functional results? A retrospective cohort study

BACKGROUND

Instability or tears of the long head of the biceps tendon (LHBT) may be present in more than 35% of rotator cuff repairs (RCR).

OBJECTIVE

To compare clinical results from patients undergoing arthroscopic RCR, according to the procedure performed at the LHBT.

DESIGN AND SETTING

Retrospective cohort study designed at the shoulder and elbow clinic of Instituto de Ortopedia e Traumatologia, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Brazil.

METHODS

Functional results among patients were compared using the American Shoulder and Elbow Surgeons (ASES) and University of California Los Angeles (UCLA) scales, according to the LHBT approach adopted: no procedure, tenotomy or tenodesis.

RESULTS

We evaluated 306 shoulders (289 patients): 133 underwent no procedure at the LHBT, 77 tenotomy and 96 tenodesis. The ASES scale at 24 months showed no difference (P = 0.566) between the groups without LHBT procedure (median 90.0; interquartile range, IQR 29), tenotomy (median 90.0; IQR 32.1) or tenodesis (median 94.4; IQR 22.7); nor did the UCLA scale (median 33; IQR 7 versus median 31; IQR 8 versus median 33; IQR 5, respectively, P = 0.054). The groups differed in the preoperative functional assessment according to the ASES and UCLA scale, such that the tenodesis group started from higher values. However, there was no difference in pre and postoperative scores between the groups.

CONCLUSION

Tenodesis or tenotomy of the LHBT, in the sample analyzed, did not influence the clinical results from RCR, as assessed using the ASES and UCLA scales.

The Arthroscopic Intra-Articular Stabilization of the Shoulder for Irreparable Rotator Cuff Tear: A New Technique Proposal

Background: Superior capsular reconstruction (SCR) has shown good results in the management of irreparable rotator cuff tears due to the depressive effect on the humeral head, but it is a technically demanding and expensive procedure.

Purpose: We hypothesized that an intra-articular neoligament that prevents the superior translation of the humeral head could give similar results in terms of the superior translation of humerus (STH) and range of motion (ROM).

Study Design: To compare our proposed technique and the SCR, we conducted a biomechanical study on 10 porcine shoulders in a custom shoulder testing system.

Methods: STH and total rotational ROM were quantified in the following four scenarios: (1) when the rotator cuff was intact, (2) after cutting the supraspinatus tendon, (3) after the reconstruction of the superior capsule by long head of the biceps tendon (LHB), and (4) after an arthroscopic intra-articular stabilization by an intra-articular graft. Our proposed technique provides the creation of a humeral and glenoid tunnel, the passage of a graft through these tunnels under arthroscopic guidance, and the graft fixation in the two tunnels. We analyzed the STH and total ROM in each scenario.

Results: With respect to the STH, we reported that the present proposed technique is characterized by a significant reduction of superior translation at 0 and 45° compared to scenario 2. In addition, the comparison between our proposed technique and SCR showed a significant difference of the STH at 0° of abduction. Total rotational ROMs of the two tenchinques were similar to scenario 2. Therefore, the use of an intra-articular ligament that prevents the STH can restore shoulder stability in irreparable rotator cuff injuries at both 0 and 45° of glenohumeral abduction without apparently limiting the total rotational ROM.

Conclusion: Our proposed technique could be an important treatment option in irreparable rotator cuff tears, especially in patients under 65 years in whom reverse shoulder arthroplasty (RSA) has shown poor results and many complications.

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.].

Rotator cuff repair vs. nonoperative treatment: a systematic review with meta-analysis

BACKGROUND

Rotator cuff (RC) tears have been widely studied as many treatment strategies have been recommended. However, optimal management for patients with RC tears is still unclear.

PURPOSE

The main aim of this systematic review was to analyze randomized controlled trials using meta-analysis to compare repair to conservative treatments for patients with any type of RC tear.

METHODS

MEDLINE, Cochrane Library (CENTRAL database), PEDro, and Scopus databases were used. Two independent reviewers selected randomized controlled trials that compared surgical to conservative treatments for RC tear patients. The studies included were assessed using Cochrane Risk of Bias 2 tools, and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to evaluate the certainty of evidence and to summarize the study conclusions.

RESULTS

Six trials were included. Pooled results showed improvement in function and pain perception in favor of the repair group at 6 months (mean difference 1.26, 95% CI -2.34, 4.85, P = .49; and -0.59, 95% CI -0.84, -0.33, P < .001, respectively), at 12 months (mean difference 5.25, 95% CI 1.55, 8.95, P = .005, for function; and -0.41, 95% CI -0.70, -0.12, P = .006, for pain) and at 24 months (mean difference 5.57, 95% CI 1.86, 9.29, P = .003, for function; and -0.92, 95% CI -1.31, -0.52, P < .001, for pain) in RC tear patients. However, these differences did not reach the minimum clinically important difference. The certainty of evidence ranged from low to moderate because of imprecision in the studies included.

CONCLUSIONS

Overall analysis showed that in patients with RC tear, repair compared with conservative treatment could result in increased pain reduction and functional improvement at 6, 12, and 24 months. Even if these effects were often statistically significant, their clinical relevance was limited. Moreover, the certainty of body of evidence ranged from low to moderate.

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.