Management of proximal biceps tendon pathology

Excellent functional outcomes in patients aged 40 years or older undergoing isolated rotator cuff repair for rotator cuff tears after primary traumatic anteroinferior shoulder dislocation

PURPOSE

To investigate the functional outcomes of patients over 40 years of age who underwent isolated rotator cuff (RC) repair (RCR) for full-thickness RC tears resulting from a primary traumatic anteroinferior shoulder dislocation and to compare these outcomes with a control group of patients who underwent RCR for instability-independent RC tears, with a minimum follow-up of two years.

MATERIALS AND METHODS

Patients aged 40 years and older were included for RCR following primary traumatic anteroinferior shoulder dislocation between 01/2012 and 06/2020 with a minimum follow-up of two years. Patients were excluded if they received an additional labral repair or capsular shift. Outcomes were compared to a control group of patients who underwent RCR without history of previous dislocations. Primary outcome measures included passive range of motion (ROM) as well as patient reported outcomes comprising the Western Ontario Shoulder Instability Index (WOSI) and Rowe score. Rates of re-dislocation were evaluated as secondary outcomes.

RESULTS

Thirty-six patients were enrolled and divided into 2 groups (n = 18, respectively). Demographic characteristics did not significantly differ (p > 0.05). At final follow-up, patients affected by instability-related RC tears showed comparable functional outcomes in terms of WOSI (427.2 ± 238.9instability group (IG) vs. 431.1 ± 252.1control group (CG); p = 0.962) and Rowe (87.5 ± 12.0IG vs. 91.1 ± 10.2CG; p = 0.339) scores as well as in terms of passive ROM (abduction: 88.1 ± 4.6°IG vs. 86.7 ± 11.5°CG; p = 0.637, forward elevation: 87.8 ± 6.2°IG vs. 88.3 ± 5.1°CG; p = 0.772, external rotation: 55.3 ± 10.5°IG vs. 50.8 ± 15.3°CG; p = 0.312, internal rotation: 65.3 ± 8.5IG vs. 68.8 ± 4.9CG, p = 0.388). No patient experienced a re-dislocation.

CONCLUSION

Patients ≥ 40 years who underwent isolated RCR without labral repair or capsular shift for a concurrent RC tear after experiencing a primary traumatic anteroinferior shoulder dislocation, achieved favorable functional outcomes along with absence of re-dislocations.

STUDY DESIGN

Retrospective case series; Level of Evidence IV.

Comparable and Improved Clinical Outcomes, Pain Relief, Return to Sport and Low Popeye Deformity Rates in Inlay Versus Onlay Open Subpectoral Biceps Tenodesis: A Systematic Review

PURPOSE

To compare clinical outcomes, failure rates, Popeye deformity, and return-to-sport (RTS) between inlay and onlay fixation techniques for open subpectoral biceps tenodesis.

METHODS

A systematic search of PubMed, EMBASE, and Cochrane Library databases was conducted for studies published between 2014 and 2024. Inclusion criteria consisted of Level I-IV studies in English, reporting clinical outcomes for open subpectoral biceps tenodesis with at least 2 years of follow-up. Data on PROMs, RTS, Popeye deformity, and failure rates were extracted. Risk of bias was assessed using the MINORS criteria. Statistical analysis was performed to evaluate heterogeneity and clinical outcomes between fixation techniques were compared using qualitative analysis and 95% confidence intervals.

RESULTS

Fourteen studies with a total of 498 patients (347 in inlay group, 151 in onlay group) were included. Postoperative American Shoulder and Elbow Surgeons scores ranged from 78.6 to 95.8, Visual Analogue Scale pain scores from 0.25 to 2.6, and Constant-Murley Scores from 26.7 to 91.8, with no differences noted between inlay and onlay techniques across these measures on qualitative assessment. RTS rates were similarly comparable, ranging from 62% to 93% across all studies. The incidence of Popeye deformity was low in both groups, ranging from 0% to 7.7% for inlay fixation and from 0% to 6.7% for onlay fixation, with no qualitative differences observed. Heterogeneity in outcomes was attributed to variations in study design and patient populations.

CONCLUSION

Both inlay and onlay fixation for open subpectoral biceps tenodesis demonstrated comparable clinical outcomes, similar pain relief, and low rates of Popeye deformity. RTS rates were consistently high across both techniques. The choice of fixation method did not significantly impact the overall results, suggesting either technique can be used effectively based on surgeon and patient preferences.

LEVEL OF EVIDENCE

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

Arthroscopic inlay suprapectoral vs. mini-open onlay subpectoral biceps tenodesis: a prospective, randomized analysis of clinical outcomes and ultrasound-assessed structural integrity

BACKGROUND

Surgical techniques for biceps tenodesis vary in approach, fixation strategy, and anatomic location without a clear superior technique for this common procedure. The purpose of this study was to prospectively evaluate a randomized cohort of patients who underwent arthroscopic suprapectoral biceps tenodesis (ASBT) with interference screw fixation using an inlay technique vs. mini-open subpectoral biceps tenodesis (MOBT) with a unicortical button implant using an onlay technique with regard to (1) clinical outcome measures and (2) structural healing as evaluated by ultrasound.

METHODS

From May 2017 to April 2021, patients who had undergone biceps tenodesis were preoperatively randomized to either ASBT or MOBT. American Shoulder and Elbow Surgeons, Single Assessment Numeric Evaluation, and visual analog scale scores were recorded at baseline, 3 months, and 2 years postoperatively. The integrity of the biceps tendon at the tenodesis site was independently examined via ultrasound by a musculoskeletal-trained radiologist at 3 months and 2 years postoperatively. t tests were performed for continuous variables, whereas χ2 tests were performed for categorical variables.

RESULTS

A total of 52 patients (24 ASBT and 28 MOBT) were randomized and completed follow-up. At baseline, 3 months, and 2 years postoperatively, the mean American Shoulder and Elbow Surgeons, Single Assessment Numeric Evaluation, and Visual Analog Scale scores were not statistically different between ASBT and MOBT. At the 3-month postoperative ultrasound, 23 of 24 (96%) ASBT patients and 26 of 28 (93%) MOBT patients were noted to have a clearly intact biceps tenodesis. At 2 years, all biceps tenodeses regardless of group were noted to be intact and healed, including all 3 shoulders whose ultrasound noted a questionably intact repair without significant retraction of the tendon at previous 3-month ultrasound evaluation.

CONCLUSION

This study demonstrates similar clinical outcomes at 2-year follow-up between ASBT and MOBT. Both groups demonstrated improvement that exceeded the reported patient acceptable symptom state and minimal clinically important difference. Ultrasound showed excellent structural healing rates for both inlay and onlay biceps tenodesis techniques.

The Superior Glenoid Humeral Ligament's Role in Superior Labrum Anterior-Posterior Lesions and Subtype Classification Based on Arthroscopic Views: A Multicenter, Retrospective Study

Background

Superior labrum anterior-posterior (SLAP) lesions are common shoulder injuries. The 10-type classification system has been widely used to diagnose SLAP lesions since it was proposed. However, growing evidence from arthroscopic studies indicates the existence of many SLAP lesions, especially those associated with superior glenoid humeral ligament (SGHL) injuries, that were not included in the initial classification.

Purpose

To introduce a SLAP classification associated with SGHL injury based on arthroscopic views and discuss the injury mechanism and corresponding treatment options.

Study Design

Cross-sectional study; Level of evidence, 3.

Methods

Patients with SLAP lesions who underwent shoulder arthroscopic surgical treatment between June 2011 and January 2017 in 6 level 1 centers were evaluated in this study. Preoperative radiographs and magnetic resonance imaging scans were used to diagnose SLAP lesions, and arthroscopic views from the standard posterior portal were recorded. The traditional 10-type classification system for SLAP was used to classify these cases. A classification method for SLAP lesions associated with SGHL injury was introduced. This classification system was investigated by 4 observers to evaluate inter- and intraobserver reliability (kappa coefficient [κ]).

Results

A total of 828 patients were included in this analysis; 61 patients (7.4%) could not be classified by the 10-type traditional classification, and 44 patients (5.3%) had SGHL lesions. A novel classification for 3 subtypes of SLAP with SGHL lesions was introduced. The mean κ value of the interobserver reliability for the classification approach was 0.796 (range, 0.678-0.854), indicating substantial agreement. The mean κ value for the intraobserver reliability was 0.883 (range, 0.779-0.964), indicating excellent agreement.

Conclusion

This study demonstrated a novel classification system for SLAP lesions associated with SGHL injury by introducing a series of cases with characteristics that showed high inter- and intraobserver reliability. Such cases have not been reported before, and the classification correlates with surgical treatment. This classification may be used as a supplement to the traditional 10-type classification.

Study on the MRI features of normal postoperative glenoid labrum compared to recurrent tears

The study evaluates the effectiveness of MRI and MR arthrograms in detecting recurrent glenoid labral tears, highlighting MRI's ability to visualize soft tissues and assess postoperative repair integrity, crucial for diagnosing labral injuries and ensuring appropriate treatment. The study included 25 patients (72% male, 28% female) with recurrent shoulder repair. Recurrent labral tears were observed in 14 patients on MR arthrogram with 81-91% sensitivity and 76-86% specificity based on age. In 12% of patients, paralabral cysts were observed. Overhead activity was present in 44% of patients and most frequently in males under 30. Recurrent labral tear is seen in most of the patients with MRI imaging. The study found that MRI and MR arthrogram are useful diagnostic instruments with comparatively high sensitivity and specificity for detecting recurrent labral tears in postoperative patients, especially in patients between 35-40 years. This retrospective study evaluates the diagnostic accuracy of MR arthrograms in detecting recurrent glenoid labral tears after surgery, analyzing sensitivity, specificity, demographics, recurrence causes and secondary findings.

Open Biceps Tenodesis and Tenotomy Have Low 30-Day Postoperative Complication Rates

Purpose

To compare 30-day postoperative rates of adverse events, particularly infection rates, between open biceps tenodesis and biceps tenotomy.

Methods

The American College of Surgeons National Surgical Quality Improvement Program was filtered using Current Procedural Terminology codes to identify patients undergoing open biceps tenodesis and tenotomy from 2010 to 2021. Patients were divided into cohorts based on procedure type. Propensity score matching was used to account for confounding variables. Statistical analyses were conducted to compare 30-day postoperative outcomes between cohorts, as well as to evaluate secondary risk factors for complications.

Results

Overall, 12,367 patients were included in the study with 11,417 undergoing open biceps tenodesis and 950 undergoing biceps tenotomy. After matching, 1,900 patients were included in the final analysis. The rate of outpatient procedures in the tenodesis cohort was significantly higher than in the tenotomy cohort. Rates of any adverse event (AAE), sepsis, pneumonia, reoperation, and extended length of stay (LOS) were significantly higher in the tenotomy cohort compared with the tenodesis cohort. There was no difference in infection rates or wound dehiscence between the 2 groups. After multivariable analysis, increasing age, longer operative time, and history of bleeding disorders were associated with significantly higher odds of developing AAE.

Conclusions

In this study, we found that tenotomy and open tenodesis are both safe options for treatment of biceps pathology. The overall rate of developing AAE and the rate of postoperative sepsis were higher in the tenotomy cohort. In addition, rates of postoperative infection and wound dehiscence did not vary between the 2 groups. Small differences were additionally observed in rates of pneumonia, return to the operating room, and extended LOS, and these rates were higher in the tenotomy cohort.

Level of Evidence

Level III, retrospective comparative study.

One-Step Release Technique for Tendon Extraction During Biceps Tenodesis

All biceps tenodesis techniques involving extra-articular tendon preparation consist of 2 distinct steps for tenotomy and tendon grasping. These 2 maneuvers are performed by different instruments. A single-step tendon release technique is described for both arthroscopic and open shoulder surgery. This technique finds application in arthroscopic proximal suprapectoral tenodesis, open treatment of proximal humerus fractures, and suprapectoral mini-open tenodesis. Herein, we describe an arthroscopic biceps tenodesis technique that combines the actions of cutting and gripping the tendon in a single step.

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.

Fast Arthroscopic Biceps Tenodesis Without Penetrating Grasper

Long head of the biceps pathology is a common cause of shoulder pain and dysfunction. Surgical treatment can be either a tenotomy or a tenodesis. Long-term results may be similar in both surgical techniques; however, the latest systematic reviews indicate that tenodesis offers superior clinical and functional results in young patients and athletes. Considering the favorable results with the biceps tenodesis, we present this arthroscopic tenodesis in which the long head of the biceps is fixed in the bicipital groove with an all-suture anchor passed directly through the tendon, providing a stable and fast fixation without using penetrating grasper.

Simple Soft Tissue Biceps Tenodesis

This article describes a simple all soft tissue technique for arthroscopic long head of the biceps tenodesis to the subscapularis tendon using posterior and anterior portals. The technique uses a PDS suture that assists in passing a braided suture through both the biceps tendon and the subscapularis to allow for the desired tenodesis. This technique is simple, safe, efficient, and less costly than other techniques.