Management of proximal biceps tendon pathology

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.

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.