The incidence of pathologic changes of the long head of the biceps tendon

Efficacy of management of associated dysfunctions on rotator cuff and long head of the biceps: systematic review

Background

The important functional role the rotator cuff (RC) and biceps play in the shoulder, the close anatomical relationship between them and the high incidence of injuries require an appropriate multidisciplinary therapeutic approach after a rigorous assessment. The objective is to identify and analyze surgical interventions, whether or not followed by a postsurgical one, of associated dysfunctions on the RC and long head of the biceps (LHB) and their effectiveness in improving shoulder functionality.

Methods

A systematic review based on PRISMA protocol was conducted using PubMed, Web of Science, PEDro, Scopus, CINAHL, and Dialnet until 22 April 2021. The main inclusion criteria were as follows: randomized clinical trials including subjects diagnosed with RC and LHB lesions who had surgical and/not post-surgical treatments. The methodological quality of trials was evaluated by the PEDro scale. Data were shown in 3 pre-established tables: (1)sample data, diagnostic methods, dysfunctions and injury frequency, interventions, outcome measures and results; (2)significance and effectiveness of interventions; and (3)comparison of the effectiveness of interventions.

Results

Eleven studies were selected. The methodological quality of ten of them was assessed as good and one excellent (PEDro scale). All articles had surgical treatments and ten had postoperative management. All trials used arthroscopy and two open surgery too. Single-row, double-row and transosseous repair were used for RC lesions, while SLAP repair, tenotomy, and tenodesis were applied to LHB injuries. Measured parameters were functionality, pain, Popeye’s sign, strength, range of motion, satisfaction degree, biceps cramping, and quality of life. All approaches in general, surgical plus postsurgical, were always effective to the parameters measured in each study. Seven trials compared tenotomy and tenodesis: four of them obtained statistically significant differences in favor of tenodesis in Popeye’s sign, cramping, satisfaction degree, and/or forearm supination strength; and one, in favor of tenotomy in cramping. All studies measured functionality using functional assessment scales. The most widely used was the Constant Score.

Conclusions

Surgical plus post-surgical interventions in associated dysfunctions on RC and LHB were effective. Tenodesis obtained better results than tenotomy in Popeye’s sign, satisfaction, and forearm supination strength. However, there was no difference regarding biceps cramping.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-021-02621-0.

Progression of long head of the biceps brachii tendon abnormality on magnetic resonance imaging after rotator cuff repair

OBJECTIVES

To correlate the deterioration of preserved long head of biceps tendon (LHB) after rotator cuff repair with preoperative and postoperative MRI factors.

METHODS

Total of 209 shoulder joints (F:M = 145:64; mean age 57.4 years) which underwent rotator cuff repair and at least two postoperative MRI scans over 10 months after surgery were included. LHB integrity was graded with a five point severity scale. LHB deterioration was defined by increased composite score of integrity and extent score between the preoperative and second postoperative MRI. For preoperative and postoperative MRI factors, size and location of superior cuff -supraspinatus and infraspinatus- and subscapularis tears, fatty degeneration of rotator cuff, preoperative LHB status, subluxation of LHB, superior labral tear, acromion type, repaired rotator cuff status, postoperative capsulitis and acromioplasty state were assessed. Logistic regression was used to evaluate the association between LHB deterioration and aforementioned factors. Same analysis was conducted for 62 shoulder joints with a long-term follow-up MRI.

RESULTS

Of the 209 shoulders, 49.3% (n = 103) showed LHB deterioration on short-term follow-up MRI. In long-term follow-up subgroup, 32 LHBs were further deteriorated. In multivariate analysis, fatty degeneration of superior cuff showed significant association with LHB deterioration in both short-term (p = .04, p = .007) and long-term subgroups (p = .004, p = .005) among preoperative and postoperative factors, respectively.

CONCLUSIONS

Degree of fatty degeneration in superior cuff is associated with LHB deterioration on postoperative MRI.

ADVANCES IN KNOWLEDGE

Our results support that tenotomy or tenodesis of LHB should be considered during rotator cuff repair, especially in patients with advanced fatty degeneration of rotator cuff.

Comparison of local infiltration analgesia and interscalene block for postoperative pain management in shoulder arthroscopy: a prospective randomized controlled trial

Background/aim

The aim of this study was to compare the effects of local infiltration analgesia and interscalene brachial plexus block techniques on postoperative pain control and shoulder functional scores in patients undergoing arthroscopic rotator cuff repair.

Materials and methods

Sixty patients who underwent arthroscopic rotator cuff repair were prospectively included in the study. Patients were randomly divided into two groups. Group 1 was comprised of patients who had interscalene brachial plexus block, while group 2 was comprised of patients who had local infiltration analgesia. In group 1, interscalene block was applied with 20 mL 0.5% bupivacaine. In group 2, the Ranawat cocktail was used for local infiltration analgesia. Sixty milliliters of Ranawat cocktail was applied to the subacromial space and glenohumeral joint in equal amounts. Postoperative pain was assessed by the VAS score. Functional scores of the shoulder were also evaluated by Constant–Murley and UCLA scores. The time of first analgesic requirement and total analgesic consumption in the postoperative period were assessed.

Results

The first analgesic requirement was significantly late in the interscalene brachial plexus block group (p = 0.000). There was no statistically significant difference between the groups in terms of total analgesic consumption (p = 0.204). In the postoperative 6th h, the VAS score was 2.43 in the interscalene brachial plexus block group, whereas 2.86 in the local infiltration analgesia group (p = 0.323). There was no statistically significant difference between the groups in terms of Constant–Murley shoulder and UCLA scores in the 3rd postoperative month (respectively, p = 0.929, p = 0.671). Besides, postoperative VAS scores and functional scores were negatively correlated (p < 0.01).

Conclusion

Local infiltration analgesia is an effective alternative to interscalene brachial plexus block for postoperative pain management and total analgesic consumption in arthroscopic rotator cuff repair. However, the interscalene brachial plexus block provides a longer postoperative painless period.

A partial articular-sided supraspinatus tear caused by the biceps tendon: A novel etiology of internal impingement

Impingement of the LHB can directly lead to articular-sided supraspinatus tears. When pain persists despite arthroscopic debridement, we recommend taking the arm out of traction intraoperatively and placing it in the 90-90 position.

Ultrasound-Guided Biceps Tendon Sheath Injections Frequently Extravasate Into the Glenohumeral Joint

PURPOSE

To evaluate the frequency of glenohumeral joint extravasation of ultrasound (US)-guided biceps tendon sheath injections.

METHODS

Fifty shoulders with a clinical diagnosis of bicipital tenosynovitis pain received a US-guided biceps sheath injection with anesthetic, steroid, and contrast (5.0 mL mixture) followed immediately by orthogonal radiographs to localize the anatomic distribution of the injection. Radiographic evaluation of contrast localization was determined and interobserver reliability calculated.

RESULTS

All 50 postinjection radiographs (100%) demonstrated contrast within the biceps tendon sheath. In addition, 30 of 50 (60%) radiographs also revealed contrast in the glenohumeral joint. Interobserver reliability for determination of intraarticular contrast was good (kappa value 0.87).

CONCLUSIONS

US-guided bicipital sheath injections reproducibly result in intrasheath placement of injection fluid. Bicipital sheath injections performed with 5 mL of volume result in partial extravasation into the joint 60% of the time. These data may be useful for surgeons who use the results of diagnostic biceps injections for diagnosis and surgical decision-making.

LEVEL OF EVIDENCE

III, prospective cohort study, diagnosis.

Measurement of biceps tendon retraction after arthroscopic tenotomy

BACKGROUND

One of the treatment options for long head of the biceps tendon (LHBT) pathology is tenotomy. To our knowledge, no study in the literature has evaluated the degree of retraction after tenotomy. The goals of this study were to determine the distance of this retraction and to identify its relationship with patient characteristics.

METHODS

We conducted an observational prospective survey over a 3-month period among 30 patients operated on arthroscopically by the same surgeon between August 2018 and April 2019. A radiopaque device was introduced inside the LHBT before tenotomy. Radiographs were obtained to evaluate the distance of retraction on day 1, day 30, and day 90.

RESULTS

Thirty patients were included, of whom 63.3% (19) were women. Surgery was performed for a rotator cuff tear in 10 patients (33.3%) and for subacromial impingement in the remainder of patients (66.7%) after failure of conservative management. The mean retraction of the LHBT (distance between the glenoid and clip) increased from 1.9 cm (day 1) to 3.5 cm (day 90). Three radiographic measurements were performed, and all 3 showed significant increases from day 1 to day 90. According to the Student t test, the mean retraction in the subacromial impingement group was significantly higher than that in the rotator cuff tear group on day 1, day 30, and day 90. Body mass index, younger age, sex, and dominant hand did not show any relation with LHBT retraction (P > .05). The mean LHBT retraction was significantly higher on day 90 in patients presenting with a positive Popeye sign (P < .05).

CONCLUSION

At 3 months of follow-up, the mean LHBT retraction was 3.5 cm from the glenoid and 2.5 cm from the greater tuberosity. It dynamically increased from day 1 to day 90. The LHBT will retract and sit beyond the transverse humeral ligament in the bicipital groove. The LHBT retracts significantly more when early mobilization of the shoulder is allowed.

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

IMPORTANCE

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

OBJECTIVE

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

EVIDENCE REVIEW

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

FINDINGS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

III.

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

Hypothesis/Background

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

Methods

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

Results

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

Discussion/Conclusion

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

Biceps tenodesis versus tenotomy: a systematic review and meta-analysis of level I randomized controlled trials

BACKGROUND

Biceps tenodesis and tenotomy are 2 surgical treatment options for relief of long head of the biceps tendon (LHBT) pathology and superior labrum anterior-to-posterior (SLAP) tears. The purpose of this systematic review was to compare the clinical outcomes and complications of biceps tenodesis and tenotomy for the treatment of LHBT or SLAP pathology during shoulder arthroscopy.

METHODS

We performed a systematic review by searching PubMed, the Cochrane Library, and Embase to identify level I randomized controlled trials that compared the clinical outcomes of biceps tenodesis vs. tenotomy. The search phrase used was as follows: biceps tenodesis tenotomy randomized. Patients were assessed based on the American Shoulder and Elbow Surgeons score, visual analog scale score for pain, and Constant-Murley score, as well as postoperative range of motion, strength, and cosmetic deformity.

RESULTS

Five studies (all level I) met the inclusion criteria, including 236 patients undergoing biceps tenodesis (mean age, 60.3 years) and 232 patients undergoing biceps tenotomy (mean age, 59.7 years). The mean follow-up period was 23.0 months. Overall, 6.8% of tenodesis patients experienced cosmetic deformity at latest follow-up compared with 23.3% of tenotomy patients (P < .001). No differences in Constant-Murley, visual analog scale, or American Shoulder and Elbow Surgeons scores were found between groups in any study, and of all the studies evaluating strength and range of motion at latest follow-up, only 1 found a significant difference between groups, in which tenodesis patients demonstrated significantly increased forearm supination strength (P = .02). One study found tenodesis patients to experience significantly more biceps cramping at 6-month follow-up compared with tenotomy patients (P = .043), although no differences in complication rates at latest follow-up were found in any study.

CONCLUSION

Patients undergoing treatment for LHBT or SLAP pathology with either biceps tenodesis or tenotomy can be expected to experience similar improvements in patient-reported and functional outcomes. There is an increased rate of cosmetic deformity in patients undergoing biceps tenotomy compared with tenodesis.

Biceps Tenodesis for Superior Labrum Anterior-Posterior Tear in the Overhead Athlete: A Systematic Review

BACKGROUND

Superior labrum anterior-posterior (SLAP) lesion is a common shoulder injury, particularly in overhead athletes. While surgical management has traditionally consisted of SLAP repair, high rates of revision and complications have led to alternative techniques, such as biceps tenodesis (BT). While BT is commonly reserved for older nonoverhead athletes, indications for its use have expanded in recent years.

PURPOSE

To determine functional outcomes and return-to-sport rates among overhead athletes after BT for SLAP tear.

STUDY DESIGN

Systematic review.

METHODS

A systematic review was performed for any articles published before July 2019. The search phrase "labral tear" was used to capture maximum results, followed by keyword inclusion of "SLAP tear" and "biceps tenodesis." Inclusion criteria included outcome studies of BT for isolated SLAP tear in athletes participating in any overhead sports, not limited to throwing alone. Abstracts and manuscripts were independently reviewed to determine eligibility. When clearly delineated, outcome variables from multiple studies were combined.

RESULTS

After full review, 8 articles met inclusion criteria (99 athletes; mean age, 19.8-47 years), with baseball and softball players the most common among them (n = 62). Type II SLAP tear was the most common diagnosis, and 0% to 44% of athletes had a failed previous SLAP repair before undergoing BT. Only 1 study included patients with concomitant rotator cuff repair. Open subpectoral BT was most commonly used, and complication rates ranged from 0% to 14%, with wound erythema, traumatic biceps tendon rupture, brachial plexus neurapraxia, and adhesive capsulitis being reported. Combined reported postoperative functional scores were as follows: American Shoulder and Elbow Surgeons, 81.7 to 97; 12-Item Short Form Health Survey physical, 50 to 54; visual analog scale for pain, 0.8-1.5; Kerlan Jobe Orthopaedic Clinic, 66 to 79; and satisfaction, 80% to 87%. The overall return-to-sports rate for overhead athletes was 70% (60 of 86). For studies that clearly delineated outcomes based on level of play/athlete, the combined return-to-sports rate was 69% (11 of 16) for recreational overhead athletes, 80% (4 of 5) for competitive/collegiate athletes, and 60% (18 of 30) for professionals.

CONCLUSION

BT in the overhead athlete offers encouraging functional outcomes and return-to-sports rates, particularly in the recreational athlete. It can be successfully performed as an index operation rather than SLAP repair, as well as in a younger patient population. Careful consideration should be given to elite overhead athletes, particularly pitchers, who tend to experience poorer outcomes.

Bicipital groove cross-sectional area on ultrasonography: Does a correlation to intra-articular tendon pathology exist?

BACKGROUND

The etiology and relevance of long head of biceps tendon (LHBT) pathology is debated. As it can have important therapeutic consequences and physical examination can be misleading, various morphologic parameters have been described to try to predict it.

HYPOTHESIS

We hypothesized that bicipital groove cross-sectional area (CSA), as assessed by ultrasonography, could be related to intra-articular tendon pathology.

MATERIAL AND METHODS

Fifty-eight consecutive consenting patients who underwent arthroscopic shoulder surgery at our hospital were selected. Diagnosis consisted mainly of rotator cuff tears, but also of anterior instability and subacromial impingement. Before surgery, ultrasonography was performed to measure width, depth and cross-sectional area of the bicipital groove. LHBT pathology was assessed during arthroscopy and classified as tendinopathy, partial disruption or complete tear and correlated to the ultrasonography measurements.

RESULTS

Bicipital groove width was of 6.7±1.2mm in patients with a normal LHBT and 7.3±1.9mm with patients with an abnormal LHBT (p=0.234). Bicipital groove depth was of 3.5±0.5mm in patients with a normal LHBT and 3.7±1.1mm with patients with an abnormal LHBT (p=0.251). Bicipital groove CSA was of 16.6±4.5 mm² in patients with a normal LHBT and 19.1±7.1 mm² with patients with an abnormal LHBT (p=0.108).

CONCLUSION

Our results do not support any correlation between LHBT pathology and the bicipital groove CSA, even though this measurement, as its width and depth, are somewhat higher in patients with a LHBT injury.

LEVEL OF EVIDENCE

I; diagnostic study.

Characterization of the Proximal Long Head of Biceps Tendon Anatomy Using Magnetic Resonance Imaging: Implications for Biceps Tenodesis

BACKGROUND

Biceps tenodesis is a common treatment for proximal long head of biceps (LHB) tendon pathology. To maintain biceps strength and contour and minimize cramping, restoration of muscle-length tension and appropriate positioning of the tenodesis is key. Little is known about the biceps musculotendinous junction (MTJ) anatomy, especially in relation to the overlying pectoralis major tendon (PMT), which is a commonly used landmark for tenodesis positioning.

PURPOSE

To characterize the in vivo topographic anatomy of the LHB tendon, in particular the MTJ relative to the PMT, using a novel axial proton-density magnetic resonance imaging (MRI) sequence.

STUDY DESIGN

Descriptive laboratory study.

METHODS

In total, 45 patients having a shoulder MRI for symptoms unrelated to their biceps tendon or rotator cuff were prospectively recruited. There were 33 men and 12 women, with a mean age of 37 ± 13 years (range, 18-59 years). All patients underwent routine shoulder MRI scans with an additional axial proton density sequence examining the LHB tendon and its MTJ. Three independent observers reviewed each MRI scan, and measurements were obtained for (1) MTJ length, (2) the distance between the proximal MTJ and the superior border of the PMT (MTJ-S), (3) the distance between the distal MTJ to the inferior border of the PMT, and (4) the width of the PMT.

RESULTS

The average position of the MTJ-S was 5.9 ± 10.8 mm distal to the superior border of the PMT. The mean MTJ length was 32.5 ± 8.3 mm and the width of the PMT was 28.0 ± 7.3 mm. We found no significant correlation between patient age, height, sex, or body mass index and any of the biceps measurements. We observed wide variability of the MTJ-S position and identified 3 distinct types of biceps MTJ: type 1, MTJ-S above the PMT; type 2, MTJ-S between 0 and 10 mm below the superior border of the PMT; and type 3, MTJ-S >10 mm distal to the superior PMT.

CONCLUSION

In this study, the in vivo anatomy of the LHB tendon is characterized relative to the PMT using a novel MRI sequence. The results demonstrate wide variability in the position of the MTJ relative to the PMT, which can be classified into 3 distinct subtypes or zones relative to the superior border of the PMT. Understanding this potentially allows for accurate and anatomic placement of the biceps tendon for tenodesis.

CLINICAL RELEVANCE

To our knowledge, this is the first study to radiologically analyze the in vivo topographic anatomy of the LHB tendon and its MTJ. The results of this study provide more detailed understanding of the variability of the biceps MTJ, thus allowing for more accurate placement of the biceps tendon during tenodesis.

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

Background:

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

Purpose:

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

Study Design:

Cross-sectional study.

Methods:

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

Results:

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

Conclusion:

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

Accuracy of long head of the biceps tendon palpation by physical therapists; an ultrasonographic study

[Purpose] Examination and treatment of the long head of the biceps tendon (LHBT) requires accurate palpation. The purpose of this study was to determine physical therapists’ reliability and ability to accurately palpate the LHBT in two arm positions with ultrasound as the gold standard. [Participants and Methods] Examiners palpated the LHBT within the intertubercular groove (ITG) of the humerus on the bilateral shoulders of 32 asymptomatic (21 female; 24.3 ± 1.9 years) participants in 2 arm positions. The magnitude of distance between a marker and the border of the ITG was compared between 2 positions using an independent t-test. Percent accuracy was calculated. [Results] Inter-rater reliability was poor (position 1, k=1.04; position 2, k=0.016). Overall accuracy rate was 45.7% (117/256). Accuracy was 49.2% (63/128) and 42.2% (54/128) for testing position 1 and position 2 respectively. Mean distance palpated from the groove was M=2.58 mm (± 6.2 mm) for position 1 and M=3.77 mm (± 6.6 mm) for position 2. Inaccurate palpation occurred medially 72.3% (47/65) and 93.2% (69/74) in position 1 and position 2 respectively. [Conclusion] Results of this study did not support one arm position being more accurate over another for LHBT palpation.

Conversion of Failed Proximal Long Head of the Biceps Tenodesis to Distal Subpectoral Tenodesis: Outcomes in an Active Population

PURPOSE

To assess failure rates and patient reported outcomes following revision of failed proximal long head of the biceps (LHB) tenodesis.

METHODS

Patients from an active-military population who underwent revision proximal (suprapectoral) to distal (subpectoral) LHB tenodesis were prospectively enrolled. Patients were included if they were between the ages of 16 and 60 years presenting after a previous biceps tenodesis with mechanical failure and clinical failure, defined as Single Assessment Numeric Evaluation (SANE) or American Shoulder and Elbow Surgeons (ASES) <70. Exclusion criteria were concomitant rotator cuff repair or debridement, full-thickness rotator cuff tear, extensive labral tears, or any evidence of glenohumeral arthritis. Pre- and postoperative SANE and ASES were documented and analyzed.

RESULTS

From 2004 to 2010, a total of 12 patients (all male) with a mean age of 39.9 years (range, 30-54 years) were assessed at a mean follow-up time of 29 months (range, 24-38 months). Nine patients presented with a failed tenodesis construct located at the top of the bicipital groove and 9 patients had LHB tendons originally affixed with an interference screw. Diagnostic arthroscopy revealed that the majority of patients (10/12) had excessive scarring at the site of previous fixation. Mean preoperative assessments of SANE (70.4) and ASES (59.9) improved postoperatively to SANE (90.3; P < .01) and ASES (89.8; P < .01). No patients were lost due to follow-up, and there were no reported complications or failures. All patients returned to full active duty and were able to perform all required physical tests before returning to their vocation.

CONCLUSIONS

Patients presenting with symptoms following a proximal LHB tenodesis can be successfully converted to a distal (subpectoral) LHB tenodesis with favorable outcomes. Although in a small sample, there was excessive scarring and synovitis in a majority, which improved significantly when treated with a revision subpectoral tenodesis with minimal complication risk and no reported failures.

LEVEL OF EVIDENCE

IV (Therapeutic case series).

Superior Capsular Reconstruction With Double Bundle of Long Head Biceps Tendon Autograft: The "Box" Technique

The superior capsular reconstruction (SCR) is an arthroscopic surgical technique recently introduced as an effective solution to restore the defect of superior articular capsule in massive rotator cuff tears that cannot be repaired anatomically. The SCR retains static stability and inhibits the proximal humeral migration, thereby optimizing the force couples about the shoulder. In this surgical technique paper, we present our technique of SCR using a double bundle construct of long head of biceps tendon, called the "box" technique. It is always combined with partial rotator cuff repair.

A new significance of an old structure: Aponeurotic expansion of supraspinatus tendon and its relationships with biceps brachii long head and rotator cuff tendons

PURPOSE

To investigate the relationship between aponeurotic expansion of supraspinatus tendon and disorders of biceps brachii long head (LHB), supraspinatus and subscapularis tendons.

METHODS

Images of 3.0 T shoulder magnetic resonance images (MRI) of a total of 154 patients and 157 shoulders (3 cases with bilateral imaging) between the ages of 18-45 were retrospectively evaluated for the presence of aponeurotic expansion. When identified it was further categorized according to its thickness. Tendinopathy and tears of LHB, supraspinatus and subscapularis tendons and LHB subluxations were evaluated individually. Statistical analyses were performed using Chi-square, Fisher's exact, Mann-Whitney U and Kruskall-Wallis tests. Odds ratio and multiple logistic regression analyses were performed when applicable. p < 0.05 was considered as statistically significant.

RESULTS

A total of 82 male and 72 female cases with a mean age of 34 (±8.2) were included. Aponeurotic expansion could be identified in 31 cases (19.8 %). MRI findings for LHB disorders in this group was significantly higher (p = 0.01). The adjusted odds ratio of having LHB tendinopathy in the presence of aponeurotic expansion was 3.25 (% 95 CI:1.29-8.19). No significant correlation was found between presence of aponeurotic expansion and subscapularis or supraspinatus tendon disorders (p = 0.66 and p = 0.792 respectively). Age was a significant variable for disorders of all three tendons (p < 0.001).

CONCLUSION

On 3.0 T MRI, findings of LHB tendon disorders were significantly more common in cases with aponeurotic expansion of supraspinatus tendon. This anatomical variation may have an unrecognized clinical significance.

Arthroscopic Biceps Tenodesis Outcomes: A Comparison of Inlay and Onlay Techniques

BACKGROUND

Arthroscopic biceps tenodesis (ABT) high in the groove can be achieved using an inlay or an onlay technique. However, there is little information comparing outcomes between the 2.

PURPOSE

To compare postoperative healing and functional outcomes of ABT high in the groove performed using either an onlay or an inlay technique.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective study was performed on patients undergoing ABT at the articular margin (high in the groove) at a single center over a 2-year period. An inlay technique using an interference screw was performed during the first year, followed by an onlay technique using a knotless suture anchor during the second. Tendon healing, elbow flexion strength, functional outcome, and complications were evaluated at a postoperative minimum of 1 year.

RESULTS

A total of 37 patients with inlay and 53 with onlay ABTs were available for follow-up. There was no difference in range of motion, functional outcome scores, or elbow flexion strength between the groups. A postoperative popeye deformity was noted in 27% of patients in the inlay group as compared with 9.4% of the onlay group (P = .028). Four patients (10.8%) in the inlay group required revision surgery (2 of which were biceps tenodesis related) as compared with 0% in the onlay group (P = .015).

CONCLUSION

An onlay technique using a knotless suture anchor for ABT at the top of the articular margin is an acceptable alternative to an inlay technique using an interference screw. The onlay technique was associated with lower rates of postoperative popeye deformity and revision surgery as compared with the inlay technique.

The Ultrasonographic Features of Shoulder Pain Patients in a Tertiary Hospital in South China

Methods

Patients with shoulder pain were recruited in an outpatient rehabilitation clinic at the Third Affiliated Hospital of Sun Yat-Sen University from January 1, 2017, to June 30, 2018. These shoulder pain patients with or without limitation in joint movement can be included in the study. All of them received musculoskeletal ultrasound scanning. Demographic and imaging data including age, gender, duration of shoulder pain, pain side, and pathologies found by musculoskeletal ultrasound imaging were collected and analyzed. Patients were divided into three groups: <45 years (young group), between 45 and 60 years (middle-aged group), and >60 years (elderly group). The rates of various shoulder pathologies were evaluated and compared between the groups.

Results

This study recruited a total of 346 patients with shoulder pain. There were more female (62.1%) than male patients (37.9%), with the largest number of patients in the 45-60 years of age group (40.5%). Forty-eight percent of patients had shoulder pain within a period of 3 months. A total of 380 shoulders were assessed using musculoskeletal ultrasound imaging. The occurrence rate of subacromial disorder (83.8%) was the highest. The rate of supraspinatus tendinopathy, acromioclavicular joint degeneration, and adhesive shoulder capsulitis varied significantly between age groups (P < 0.05). The rate of acromioclavicular joint degeneration was the highest in the elderly group followed by the middle-aged and young groups (P < 0.0167). The rate of supraspinatus tendinopathy and adhesive capsulitis in the middle-aged and elderly groups was significantly higher than that in the young group (P < 0.0167).

Conclusions

Musculoskeletal ultrasound can be a useful imaging tool in making an accurate diagnosis of shoulder pain. The occurrence rates of different shoulder pain pathologies in all age groups were thoroughly calculated in this study. More female and more subcoracoid disorder patients than western countries are attributed to repetitive lifting in daily life and work in this study. Correlations between these pathologies and their associated images can be a solid foundation for the development of artificial intelligence in diagnosing the cause of shoulder pain.

What happens to the long head of the biceps tendon after arthroscopic rotator cuff repair?

Aims

The purpose of this study was to identify the changes in untreated long head of the biceps brachii tendon (LHBT) after a rotator cuff tear and to evaluate the factors related to the changes.

Methods

A cohort of 162 patients who underwent isolated supraspinatus with the preservation of LHBT was enrolled and evaluated. The cross-sectional area (CSA) of the LHBT on MRI was measured in the bicipital groove, and preoperative to postoperative difference was calculated at least 12 months postoperatively. Second, postoperative changes in the LHBT including intratendinous signal change, rupture, dislocation, or superior labral lesions were evaluated with seeking of factors that were correlated with the changes or newly developed lesions after rotator cuff repair.

Results

The postoperative CSA (12.5 mm2 (SD 8.3) was significantly larger than preoperative CSA (11.5 mm2 (SD 7.5); p = 0.005). In total, 32 patients (19.8%) showed morphological changes in the untreated LHBT 24 months after rotator cuff repair. Univariate regression analysis revealed that the factor chiefly related to the change in LHBT status was an eccentric LHBT position within the groove found on preoperative MRI (p = 0.011). Multivariate analysis using logistic regression also revealed that an eccentric LHBT position was a factor related to postoperative change in untreated LHBTs (p = 0.011).

Conclusion

The CSA of the LHBT inside the biceps groove increased after rotator cuff repair. The preoperative presence of an eccentrically positioned LHBT was associated with further changes of the tendon itself after rotator cuff repair. Cite this article: Bone Joint J 2020;102-B(9):1194–1199.

Prevalence of rotator cuff diseases in adults older than 40 years in or near Chuncheon city, Korea

Background

To determine the prevalence of rotator cuff diseases in a population older than 40 years in or nearby Chuncheon city, Republic of Korea.

Methods

Sixty shoulders of 30 people older than 40 years who participated in a health lecture were examined for free by an orthopedic surgeon. Visual analog scale of pain and American Shoulder and Elbow Surgeons scores were assigned, and routine physical examination was performed. Ultrasonography was performed on the shoulder.

Results

On ultrasonographic examination, there were one shoulder with full thickness rotator cuff tear, 20 of 60 (33%) with partial thickness rotator cuff tear, five of 60 (8%) with calcific tendinitis, one of 60 (2%) with tear of the long head of the biceps, and five of 60 (8%) with tendinitis of the long head of the biceps. Participants older than 60 years showed significantly high proportions of lesion of the long head of the biceps and rotator cuff diseases (P=0.019 and P=0.015, respectively). Participants who performed physical labor had high proportions of rotator cuff tear and rotator cuff disease (P=0.001 and P<0.001, respectively).

Conclusions

Rotator cuff diseases showed a high prevalence in aged persons and resulted in a decrease in shoulder function.

Arthroscopic supraglenoid origin-preserving biceps tenodesis: a reliable, simple, and cost-conscious technique

BACKGROUND

The purpose of this study was to assess the midterm clinical and ultrasonographic outcomes of a new all arthroscopic supraglenoid origin-preserving tenodesis technique of the long head of the biceps (LHB) brachii tendon in the setting of small to medium-sized rotator cuff repairs.

MATERIALS AND METHODS

Thirty patients (33 shoulders) meeting inclusion criteria were identified who underwent LHB tenodesis with this technique in the setting of small to medium-sized rotator cuff repair at a mean age at surgery of 65.6 years between 2015 and 2017. Rotator cuff tears were repaired using the Southern California Orthopedic Institute (SCOI) row technique. The biceps tenodesis was incorporated into the anterior anchor of the rotator cuff repair after bony groove preparation, including débridement and bone vent placement. Frayed edges of the biceps tendon were gently débrided, but the intra-articular glenoid attachment was left intact. Patients were assessed at follow-up by clinical and ultrasonographic examination, as well as a satisfaction questionnaire, the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score and visual analog scale (VAS) score.

RESULTS

Mean follow-up was 32.9 months for the 27 patients (30 shoulders), resulting in a 91% follow-up. Average ASES score was 94.4. Average patient-reported satisfaction with shoulder function was 9.4 of 10 and with biceps contour was 9.9 of 10. Average VAS score was 0.6 of 10, and 73% of patients reported a VAS score of 0. Ultrasonography demonstrated an intact biceps tendon in 27 of 28 shoulders and an intact supraspinatus tendon in all 28 shoulders. Mean range of motion was 170° in forward flexion, 169° in abduction, 49° in external rotation, and to thoracic vertebrae 12 in internal rotation. Mean muscle grading during Jobe test was 4.8 of 5. There were no intraoperative complications. No patients required revision surgery.

CONCLUSIONS

In situ arthroscopic biceps tenodesis with maintenance of the glenoid attachment incorporated into rotator cuff repair yields a high rate of healing and consistently excellent functional and cosmetic outcomes as well as patient satisfaction while saving surgical time and cost.

Use of Platelet-Rich Plasma for the Improvement of Pain and Function in Rotator Cuff Tears: A Systematic Review and Meta-analysis With Bias Assessment

BACKGROUND

Many clinical trials have investigated the use of platelet-rich plasma (PRP) to treat rotator cuff-related abnormalities. Several meta-analyses have been published, but none have focused exclusively on level 1 randomized controlled trials.

PURPOSE

To assess the efficacy of PRP for rotator cuff-related abnormalities and evaluate how specific tendon involvement, the inclusion of leukocytes, and the use of gel/nongel formulations affect pain and functional outcomes.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

The literature was screened following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Baseline, short-term, and long-term data were extracted for the Constant score, University of California, Los Angeles (UCLA) score, visual analog scale (VAS) for pain, retear rate, Simple Shoulder Test (SST), and American Shoulder and Elbow Surgeons (ASES) score. The 100-point modified Coleman Methodology Score (CMS) was used to assess methodological quality. Funnel plots and the Egger test were used to screen for publication bias, and sensitivity analysis was performed to evaluate the effect of potential outliers.

RESULTS

A total of 18 level 1 studies were included in this review, 17 (1116 patients) of which could be included in quantitative analysis. The mean modified CMS was 79.4 ± 10.39. The Constant scores of patients who received PRP were significantly better short term (weighted mean difference [WMD], 2.89 [95% CI, 0.89-4.90]; P < .01) and long term (WMD, 2.66 [95% CI, 1.13-4.19]; P < .01). The VAS scores were significantly improved short term (WMD, -0.45 [95% CI, -0.75 to -0.15]; P < .01). Sugaya grade IV and V retears in PRP-treated patients were significantly reduced long term (odds ratio [OR], 0.34 [95% CI, 0.20-0.57]; P < .01). In PRP-treated patients with multiple tendons torn, there were reduced odds of retears (OR, 0.28 [95% CI, 0.13-0.60]; P < .01). Patients who received leukocyte-rich PRP had significantly better Constant scores compared with the leukocyte-poor PRP group, but there was no difference in VAS scores. Patients receiving PRP gel reported higher Constant scores compared with the controls, whereas those receiving nongel PRP treatments did not, although there was no difference in VAS scores. Long-term odds of retears were decreased, regardless of leukocyte content (leukocyte-poor PRP: OR, 0.36 [95% CI, 0.16-0.82]; leukocyte-rich PRP: OR, 0.32 [95% CI, 0.16-0.65]; all P < .05) or usage of gel (nongel: OR, 0.42 [95% CI, 0.23-0.76]; gel: OR, 0.17 [95% CI, 0.05-0.51]; all P < .01).

CONCLUSION

Long-term retear rates were significantly decreased in patients with rotator cuff-related abnormalities who received PRP. Significant improvements in PRP-treated patients were noted for multiple functional outcomes, but none reached their respective minimal clinically important differences. Overall, our results suggest that PRP may positively affect clinical outcomes, but limited data, study heterogeneity, and poor methodological quality hinder firm conclusions.

The Saber Technique for Biceps Tenotomy

Long head of the biceps (LHB) pathology is a prevalent cause of shoulder pain. Arthroscopic tenotomy and tenodesis are performed for treatment at increasing frequency. When LHB pathology is the only glenohumeral intra-articular pathology that needs to be addressed, and an LHB tenotomy or subpectoral LHB tenodesis is planned, it is unnecessary and potentially harmful to establish an anterior rotator interval portal. The objective of this Technical Note is to describe a minimally invasive technique for LHB tenotomy at the supraglenoid tubercle without the need for establishing an accessory portal.

The inflamed biceps tendon as a pain generator in the shoulder: A histological and biomolecular analysis

INTRODUCTION

The long head of the biceps (LHB) is often resected in shoulder surgery. However, its contribution to inflammatory processes in the shoulder remains unclear. In the present study, inflamed and noninflamed human LHBs were comparatively characterized for features of inflammation.

MATERIALS AND METHODS

Twenty-two resected LHB tendons were classified into inflamed ( n = 11) and noninflamed ( n = 11) samples. For histological examination, samples were stained with hematoxylin eosin, Azan, van Gieson, and Masson Goldner trichrome. Neuronal tissue was immunohistochemically visualized. In addition, specific inflammatory marker gene expression of primary LHB-derived cell cultures were analyzed.

RESULTS

Features of tendinopathy, such as collagen disorganization, infiltration by inflammatory cells, neovascularization, and extensive neuronal innervation were found in the tendinitis group. Compared to noninflamed samples, inflamed LHBs showed a significantly increased inflammatory marker gene expression.

CONCLUSION

Structural and biomolecular differences of both groups suggest that the LHB tendon acts as an important pain generator in the shoulder joint. These findings can, on the one hand, contribute to the understanding of the biomolecular genesis of LHB tendinitis and, on the other hand, provide possibilities for new therapeutic approaches.

Inter- and intra-observer reproducibility of ultrasound analysis of the long head of the biceps

INTRODUCTION

Ultrasound assessment of the long head of the biceps (LHB) is difficult. The aim of the present study was to analyze the inter- and intra-observer reproducibility of 2 ultrasound cross-sections not previously assessed: humeral head apex (image 1) and bicipital groove entrance (image 2).

HYPOTHESIS

These ultrasound cross-sectional images allow reliable and reproducible analysis of the intra-articular LHB.

MATERIAL AND METHODS

A single-center prospective study was conducted. Inter-observer reproducibility was assessed between 2 radiologists in 20 healthy shoulders (asymptomatic group) and 35 painful shoulders (symptomatic group); intra-observer reproducibility was assessed for 1 observer in 10 healthy shoulders. Quantitative parameters comprised short and long axes and transverse area, and qualitative parameters comprise echogenicity and LHB position.

RESULTS

On images 1 and 2, inter-observer agreement on the 3 quantitative parameters was good to excellent in both subject groups (p<0.05), and more precise and highly reproducible for image 1. Agreement on the 2 qualitative parameters was excellent (p<0.001). Intra-observer reproducibility results were non-significant on all parameters.

DISCUSSION

The 2 intra-articular LHB cross-sections proved reliable and reproducible in painful and in healthy shoulders. A standardized ultrasound protocol could thus enhance the precision of LHB assessment and treatment. The difficulties of LHB measurement, often related to shoulder pathology, may, however, hinder interpretation.

LEVEL OF EVIDENCE

III, prospective intra- and inter-observer study.

Should long head of biceps tenodesis or tenotomy be routinely performed in arthroscopic rotator cuff repairs?

Purpose

The long head of the biceps tendon (LHBT) lesions are frequently associated with partial or complete rotator cuff tears (RCTs), but controversy revolves around their optimal surgical management.

Methods

Hence this article aims to review the current literature available on the role of biceps surgery in rotator cuff surgery and whether it should be routinely performed in rotator cuff repairs.

Results

Furthermore, we also discuss the advantages and drawbacks of tenotomy or tenodesis of LHBT in rotator cuff surgery.

Conclusion

We conclude this article with recommendations for surgeons performing rotator cuff repairs and future research in this area.

Prevalence and risk factors for development of subscapularis and biceps pathology in shoulders with degenerative rotator cuff disease: a prospective cohort evaluation

BACKGROUND

The prevalence of subscapularis and long head of biceps (LHB) in relation to the presence and severity of posterosuperior (PS) rotator cuff disease is not known.

METHODS

Subjects with asymptomatic rotator cuff tears were enrolled for this prospective longitudinal study (n = 354) and followed annually with shoulder ultrasonography and clinical evaluations to assess for the presence of subscapularis, LHB, and PS rotator cuff pathology and pain development.

RESULTS

Subscapularis pathology developed in 14% of shoulders over a median follow-up of 5 years, with partial-thickness tearing occurring most commonly (83%). Age, sex, and hand dominance were not associated with subscapularis pathology. A greater proportion of concomitant full-thickness PS cuff tears were observed in shoulders that developed subscapularis tears (76% vs. 50%, P = .002). The PS cuff tear width (10 mm vs. 14 mm, P = .01) at the time of enrollment and both tear width (10 mm vs. 15 mm, P = .003) and length (12 mm vs. 15.5 mm, P = .02) at the time of diagnosis of subscapularis pathology were greater in subscapularis-torn shoulders. LHB pathology was prevalent in 34% of shoulders, with dislocation/subluxation occurring in 63% and higher prevalence in subscapularis-torn shoulders (71% vs. 12%, P < .01). Subscapularis-torn shoulders were more likely to develop pain (67% vs. 45%, P = .004), and concomitant PS cuff tear enlargement was associated with greater risk for pain development (76% vs. 36%, P = .01).

CONCLUSIONS

The development of subscapularis and LHB pathology is significantly related to the size of the PS cuff tear. Subscapularis involvement is associated with greater risk of pain development in degenerative rotator cuff disease.

Arthroscopic Suprapectoral and Open Subpectoral Biceps Tenodeses Produce Similar Outcomes: A Randomized Prospective Analysis

PURPOSE

To directly compare subjective and objective outcomes of arthroscopic suprapectoral biceps tenodesis (ASPBT) below the bicipital groove and open subpectoral biceps tenodesis (OSPBT) performed with interference screw fixation.

METHODS

A total of 77 patients indicated for biceps tenodesis who met the inclusion and exclusion criteria were randomized into the ASPBT and OSPBT groups. All tenodesis procedures implemented PEEK (polyether ether ketone) interference screws. Patients underwent a clinical examination that included range of motion and strength assessment at 3, 6, and 12 months postoperatively. Patients completed the American Shoulder and Elbow Surgeons (ASES) shoulder score, Single Assessment Numeric Evaluation score, and Constant score preoperatively and at 6 and 12 months postoperatively.

RESULTS

Seventy-five patients were analyzed with a mean age of 50.3 ± 10.4 years and a mean body mass index of 28.9 ± 6.3. All patients had arthroscopic evidence of biceps pathology and underwent either an ASPBT (n = 37) or OSPBT (n = 38). The surgical time was significantly greater for ASPBT than for OSPBT (16.9 ± 8.4 minutes vs 9.8 ± 3.1 minutes, P < .001). One patient underwent conversion from the ASPBT group to the OSPBT group because of shearing of a severely attenuated tendon preventing an ASPBT. No significant difference (P > .05) was found in strength or anterior shoulder pain at 3 months, 6 months, and 1 year, and no significant difference (P > .05) was found in clinical outcome scores (ASES, Constant subjective, and Single Assessment Numeric Evaluation) between the 2 groups at 6 months and 1 year. The improvement in the ASES score exceeded the minimal clinically important difference (12 points) in both groups.

CONCLUSIONS

No differences in patient-reported outcome measures, functional outcomes, or complication rates were found after ASPBT compared with OSPBT. However, the results of this investigation must be interpreted with caution because this study may be underpowered to detect statistical differences.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

Biceps tenotomy has earlier pain relief compared to biceps tenodesis: a randomized prospective study

PURPOSE

 Surgical management for long head of the biceps (LHB) tendinopathy with either biceps tenotomy or tenodesis is a reliable, but debated treatment option. The aim of this prospective, randomized, single-blinded study is to evaluate differences in pain relief and subjective outcomes between biceps tenotomy versus tenodesis for LHB tendinopathy.

METHODS

 Subjects were randomized and blinded to biceps tenotomy versus arthroscopic tenodesis intra-operatively. Outcomes evaluated included subjective patient outcome scores, pain, and cosmetic deformity. Subjective outcomes scores and pain were analyzed using a two-way ANOVA, controlling for concomitant rotator cuff repair. Binary outcomes were compared using Chi-square tests.

RESULTS

 Thirty-four subjects (31 male, 3 female) with a median age of 56 (range 30-77) were enrolled. Twenty subjects were randomized to tenotomy and 14 to tenodesis. Fifty-six percent had concomitant rotator cuff repairs. The mean VAS pain score at 3 months was lower with tenotomy versus tenodesis. 2-year follow-up demonstrated no statistically significant differences for VAS, ASES, or SANE. 15/20 (75%) subjects with biceps tenotomy reported no pain medication use at the 2-week postoperative visit versus 5/14 (33%) for biceps tenodesis. Popeye deformity was found in 5/20 (25%) of tenotomy subjects versus 1/14 (7%) in tenodesis subjects.

CONCLUSION

Outcomes appear similar between biceps tenotomy versus tenodesis; however, the tenotomy group demonstrated greater incidence of cosmetic deformity but an earlier improvement in postoperative pain.

LEVEL OF EVIDENCE

Treatment Studies, Level II.

Posterior subacromial injections are superior in differentiating a rotator cuff from a biceps pathology: A cadaveric study

Backgroud

the ideal route and accuracy of subacromial injections in shoulder pathologies are often questioned. This study aimed at comparing anterior and posterior injections in terms of subacromial space dye localization and diagnostic accuracy. We hypothesized that posterior injections would prove more accurate.

Methods

lidocaine-dye mix was injected posteriorly and anteriorly in five cadaveric shoulders each. Presence of dye was ascertained at dissection.

Results

All five posterior injections remained confined to the subacromial space. In all five anteriorly injected shoulders, the dye was seen leaking from the subacromial space into bicipital groove.

Conclusions

Varying accuracies of anterior [69-90%] and posterior [56-80%] subacromial injections have been reported. We observed both routes to be equally accurate [100%]. The dye exclusively remained within the subacromial space with posterior injections. This has higher diagnostic value in differentiating subacromial and long head of biceps pathologies. The anterior approach may have a better therapeutic role in combined subacromial and biceps pathologies.

Association of high sensitivity C-reactive protein with tearing of the long head of the biceps tendon

Background

This study proposed to investigate whether high-sensitivity C-reactive protein (hs-CRP) is an independent risk factor for long head of biceps tendon (LHBT) tear and whether hs-CRP can increase accuracy in diagnosing LHBT tear.

Methods

This study involved 582 shoulders of 557 consecutive patients who received arthroscopic examinations at the authors’ institution between January 2010 and July 2018. The strengths of associations between LHBT tear and various factors were determined by calculating the odds ratios (ORs), with 95% confidence intervals (CIs), using logistic regression analyses. The studied variables were demographic, physical, social, metabolic, comorbidity, hs-CRP, and pain on a visual analog scale (VAS) factors, as well as those related to rotator cuff tear (RCT). Significant factors in the multivariable logistic analysis were evaluated to determine their diagnostic values, including their likelihood ratios and post-test probabilities for LHBT tear.

Results

In the multivariable analysis, five variables were significant: age, retraction degree of Patte, subscapularis tendon tear, hs-CRP > 1 mg/L, and pain VAS (p ≤ 0.01). The best combination of determinations for diagnosing LHBT tear, which yielded a strong positive likelihood ratio of 19.07 and a high post-test probability of 96%, was age ≥ 67 years, subscapularis tendon tear, grade of Patte ≥2, hs-CRP > 1, and pain VAS ≥ 7.

Conclusions

Serum hs-CRP > 1 mg/L is an independent risk factor for LHBT tear, along with the expected risk factors of age, subscapularis tendon tear, retraction degree of Patte, and pain VAS. Serum hs-CRP > 1 mg/L increases the diagnostic accuracy for LHBT tear.

Level of evidence

Level IV, Clinical case series.

Does bicep pathology affect rotator cuff repair outcomes?

INTRODUCTION

Rotator cuff (RC) tears are common and a frequent cause of dysfunction in the shoulder, especially with progression of age. Biceps pathology occurs concomitantly and its relationship with RC tears has been well described. However, the study of biceps intervention affecting outcomes of RC repair is limited. We aim to study the effect of biceps tenotomy in RC repair after matching for cuff tear size.

METHODS

We collected data of 24 consecutive patients undergoing RC repair and biceps tenotomy and matched them with patients undergoing RC repair only ( n = 24). The groups were matched for age, RC tear size, and presence of subscapularis tears. All patients of this study underwent RC repair under a single surgeon. Patient demographics and outcome measures in the form of range of motion (ROM) pain scores and validated shoulder scores (Constant shoulder score, Oxford score, and University of California Los Angeles shoulder score) were collected preoperative and at predetermined fixed intervals up to 2 years postoperatively. We then compared the two groups using a mixed analysis of variance design so as to identify any possible differences.

RESULTS

Patients from both groups demonstrated significant improvement in ROM, lower pain scores, and improvement in functional outcomes ( p < 0.05). Patients with biceps intervention demonstrated equivalent outcomes postoperatively up to 2 years with no statistical differences ( p > 0.05).

CONCLUSION

Arthoscopic RC repair is an effective intervention for improving ROM, reducing pain, and improving function. Concomitant biceps procedure did not negatively impede recovery or affect outcomes.

Rotator cuff tear with concomitant long head of biceps tendon (LHBT) degeneration: what is the preferred choice? Open subpectoral versus arthroscopic intraarticular tenodesis

BACKGROUND

Lesions associated with the biceps tendon are commonly detected during arthroscopic repair of rotator cuff tears. Acquiring a preferable technique to repair both cuff and long head of biceps tendon (LHBT) lesions was the aim of several recent studies. This study aimed to compare clinical and functional outcomes of open subpectoral versus arthroscopic intraarticular tenodesis in patients with repairable rotator cuff tear associated with LHBT degeneration.

PATIENTS AND METHODS

In this randomized clinical trial, 60 eligible candidates for arthroscopic rotator cuff repair (mean age 55.7 ± 6.9 years) were allocated to a control group (open subpectoral, SP) or intervention group (intraarticular, IA). In the IA group, an anchor suture was used for both rotator cuff repair and LHBT tenodesis. In the SP group, after arthroscopic repair of the rotator cuff, subpectoral tenodesis of LHBT was performed using an interference screw. Patients were evaluated for 2 years follow-up regarding pain intensity using the visual analogue scale (VAS) and shoulder function using the Constant Score and Simple Shoulder Test.

RESULTS

The two groups were similar with regard to demographic characteristics and preoperative evaluations (all P > 0.05). The functional status of both groups was improved, but not significantly differently so between the two groups (P = 0.1 and P = 0.4, respectively). Pain intensity decreased during the 2-year follow-up period, similarly so in the two groups. Patient satisfaction was also similar in the two groups.

CONCLUSION

Large and massive rotator cuff tears (tears > 3 cm) associated with LHBT pathologies benefited from intraarticular or subpectoral tenodesis similarly, with no differences in short- or mid-term results between these two techniques.

LEVEL OF EVIDENCE

II.

Clinical Outcomes After Biceps Tenodesis or Tenotomy Using Subpectoral Pain to Guide Management in Patients With Rotator Cuff Tears

PURPOSE

To assess whether preoperative subpectoral tenderness in patients with rotator cuff tears was associated with arthroscopic findings of tendinopathy of the long head of the biceps, as well as whether they had resolution of their subpectoral tenderness postoperatively after tenodesis or tenotomy.

METHODS

Patients presenting between 2011 and 2016 undergoing arthroscopic rotator cuff repair were evaluated preoperatively with the subpectoral biceps test (SBT). This test is performed with the arm adducted and internally rotated to allow palpation of the biceps as it courses under the pectoralis major tendon. Preoperative SBT findings determined operative management with either tenodesis or tenotomy during rotator cuff repair. Patients were followed up postoperatively to assess resolution of subpectoral tenderness with a repeated SBT. Preoperative and postoperative Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Surgeons, and Constant-Murley scores were recorded in all patients.

RESULTS

A total of 128 patients were enrolled in the study, with a mean age of 58 years (range, 33-82 years). Patients with a positive preoperative SBT (n = 68) had significantly lower SANE and Constant-Murley scores preoperatively (P < .01) than patients with a negative SBT (n = 60). All patients with a positive preoperative SBT underwent either tenodesis or tenotomy, with 94% of patients (n = 64) having resolution of subpectoral pain and tenderness at final follow-up. Intraoperatively, 93% of patients with a positive SBT showed gross pathologic changes in the tendon (fraying, erythema, tears, or subluxation) compared with only 65% of patients with negative preoperative examination findings (P < .01). American Shoulder and Elbow Surgeons, Constant-Murley, and SANE scores were significantly increased postoperatively in all patients (P = .02).

CONCLUSIONS

In this group of patients with rotator cuff tears surgically treated with concomitant biceps tenodesis or tenotomy, 94% had resolution of their subpectoral tenderness. A positive SBT was associated with gross pathologic changes of the biceps in 93% of patients.

LEVEL OF EVIDENCE

Level III, prospective comparative study.

Accuracy of MRI in diagnosing intra-articular pathology of the long head of the biceps tendon: results with a large cohort of patients

Background

It is difficult to diagnose the pathology of the long head of the biceps tendon (LHBT) clinically. This study aimed to determine the diagnostic value of standard non-enhancing magnetic resonance imaging (MRI) for detecting LHBT pathology and identify the most useful diagnostic signs on MRI.

Methods

A total of 554 patients with preoperative 3-Tesla (3 T) MRI who underwent arthroscopic surgery for rotator cuff tears were retrospectively enrolled. Abnormal signs of LHBT on MRI included diameter change, contour irregularity, and alteration of signal intensity. Arthroscopic findings were classified according to tear progress and used as a reference standard: Type I, normal tendon; Type II, hourglass-shaped hypertrophic tendon with fraying extending into the bicipital groove; Type III, partial tear involving less than 50% of tendon width at the intraarticular region without fraying in the bicipital groove; Type IV, partial tear involving more than 50% of tendon width and extending into the bicipital groove; and Type V, complete tear (cutoff) of the tendon. Using receiver operating characteristic, prediction accuracies of MRI findings were assessed compared to those of arthroscopic findings.

Results

Arthroscopic findings showed LHBT pathology in 124 (22.4%) cases. High diagnostic efficacy was achieved when ‘at least 2 abnormal signs’ was set as diagnostic criteria (sensitivity: 77.9%; specificity: 93.7%; positive predictive value: 76.3%). Types II and III lesions showed the highest sensitivities (36.8 and 66.7%, respectively) in abnormal alteration of signal intensity in the parasagittal view while Type IV showed the highest sensitivity (82.3%) in diameter change in axial view. Interobserver agreements were substantial to almost perfect, with kappa value of 0.69–0.81.

Conclusions

The standard non-enhancing 3 T MRI had a high diagnostic value in preoperative detection of LHBT pathology. Its accuracy was increased when diagnostic criterion was set as ‘2 or more abnormal signs (diameter change, contour irregularity, and alteration of signal intensity)’. The single diagnostic sign with the highest sensitivity was alteration of signal intensity in the parasagittal view.

Superior capsular reconstruction for irreparable supraspinatus tendon tears using the long head of biceps: A biomechanical study on cadavers

INTRODUCTION

The superior articular capsule complements the rotator cuff's function in shoulder stability. With irreparable rotator cuff tears, superior capsular reconstruction (SCR) improves dynamic glenohumeral (GH) joint kinematics. We present a novel method of SCR in cadaveric shoulders using the long head of bicep (LHB) tendon instead of previously explored fascia lata autograft, thereby reducing harvest site and suture anchor associated complications.

HYPOTHESIS

This novel method of SCR using the LHB is feasible biomechanically in restoring shoulder stability in irreparable supraspinatus tendon tear.

MATERIALS AND METHODS

Seven cadaveric shoulders were tested in a custom shoulder testing system. Superior translation of the humerus, subacromial contact pressure and area, and glenohumeral range of motion were tested at 0°, 30°, and 60° of glenohumeral abduction in the following conditions: (1) intact shoulder, (2) simulated complete supraspinatus tendon tear, (3) modified SCR using LHB, (4) and modified SCR using LHB and side-to-side repair augmentation.

RESULTS

The complete cuff tear shifted the humeral head superiorly as compared to the intact shoulder. Subacromial peak contact pressure was also increased at 30° and 60° while contact area was increased at 0° and 30°. The modified SCR both with and without side-to-side repair shifted the humeral head inferiorly at 30° and 60°, with contact area further reduced at 60°. Both techniques had comparable results for contact pressure and total rotational range of motion.

CONCLUSION

The LHB with appropriate distal insertion on the greater tuberosity restores shoulder stability in irreparable rotator cuff tears by re-centering the humeral head on the glenoid.

LEVEL OF EVIDENCE

Basic science study, biomechanical testing.

Biceps Tenodesis Is a Viable Option for Management of Proximal Biceps Injuries in Patients Less Than 25 Years of Age

PURPOSE

To evaluate outcomes after biceps tenodesis performed in patients younger than 25 years, to evaluate reoperations and complications in this population, and to critically appraise return to preinjury level of play for this population.

METHODS

Forty-five consecutive patients younger than 25 years underwent subpectoral biceps tenodesis for biceps tendinopathy or biceps-labral complex injuries including SLAP tears. Biceps tenodesis was performed using an interference screw technique. Patients with a minimum 2-year follow-up were analyzed. Functional outcomes were assessed with the visual analog scale score, American Shoulder and Elbow Surgeons (ASES) score, ASES functional score, Simple Shoulder Test score, and range of motion. Activity level and return to sport were followed postoperatively.

RESULTS

Of the 45 patients younger than 25 years who underwent biceps tenodesis, 36 (80%) were available for follow-up at a minimum of 2 years, with a mean age of 19.8 years and mean follow-up period of 38.6 months. Of these 36 patients, 34 (94%) were athletes, with 20 patients playing at collegiate level. All clinical outcome scores improved, with the ASES score improving from 54.7 to 81.7, the ASES functional score improving from 17.5 to 25.1, and the Simple Shoulder Test score improving from 7.4 to 10.1 (P < .001). At the time of follow-up, 4 patients (11%) had undergone revision surgery for other injuries. Of the 34 athletes, 25 (73%) returned to sports, with 19 returning at the same level and 6 returning at a lower level of play; 77% of overhead athletes returned to sports.

CONCLUSIONS

When indicated, biceps tenodesis offers an alternative to SLAP repair in young patients. Biceps tenodesis in patients younger than 25 years yields satisfactory outcomes, with two-thirds of patients returning to sport and a low revision rate.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Complications of biceps tenodesis based on location, fixation, and indication: a review of 1526 shoulders

BACKGROUND

Long head of the biceps tendon (LHBT) tenodesis is predominantly performed for 2 reasons: anterior shoulder pain (ASP) or structural reasons (partial tear, dislocation).

METHODS

Between 2006 and 2014, all cases of primary LHBT tenodesis performed at an integrated health care system were retrospectively reviewed. Complications were analyzed by tenodesis location (below or out of the groove [OOG] vs leaving tendon in the groove [ITG]), fixation method (soft tissue vs implant), and indication (preoperative ASP vs structural).

RESULTS

Among 1526 shoulders, persistent ASP did not differ by fixation method (11.0% for implant vs 12.8% for soft tissue, P = .550) or location (10.8% for OOG vs 12.9% for ITG, P = .472). Soft-tissue tenodesis cases had more frequent new-onset ASP (11.9% vs 2.6%, P < .001) and subjective weakness (8.50% vs 3.92%, P < .001) but less frequent revisions (0% vs 1.19%, P = .03) than implant tenodesis cases. No difference was found between ITG and OOG for persistent ASP (12.9% vs 10.8%, P = .550), new-onset ASP (6.5% vs 2.8%, P = .339), cramping (1.70% vs 2.31%, P = .737), deformity (4.72% vs 4.62%, P = .532), or subjective weakness (6.23% vs 4.32%, P = .334), but ITG cases had more revisions (1.51% vs 0.60%, P = .001). Among implant tenodesis cases, 1 shoulder (0.085%) sustained a fracture.

CONCLUSION

The overall complication rate of LHBT tenodesis was low. Of the shoulders, 10.8% to 12.9% continued to have ASP, regardless of whether the LHBT was left ITG. Soft-tissue tenodesis cases had higher rates of new-onset ASP and subjective weakness. No significant difference for tenodesis ITG or OOG was found in biceps-related complications.

MRI, arthroscopic and histopathologic cross correlation in biceps tenodesis specimens with emphasis on the normal appearing proximal tendon

PURPOSE

To correlate the histopathologic appearances of resected long head of the biceps tendon (LHBT) specimens following biceps tenodesis, with pre-operative MRI and arthroscopic findings, with attention to the radiologically normal biceps.

MATERIAL AND METHODS

Retrospective analysis of patients who had undergone preoperative MRI, subsequent arthroscopic subpectoral tenodesis for SLAP tears and histopathologic inspection of the excised sample between 2013 and 16. Those with a normal MRI appearance or mildly increased intrasubstance signal were independently analyzed by 2 blinded radiologists. A blinded orthopedic surgeon and pathologist reviewed all operative imaging and pathologic slides, respectively.

RESULTS

Twenty-three LHBT resected samples were identified on MRI as either normal (Reader 1 n = 15; Reader 2 n = 14) or demonstrating low-grade increased signal (Reader 1 n = 8; Reader 2 n = 9). Of these, 86.9% demonstrated a histopathological abnormality. 50% of samples with histopathological abnormality demonstrated normal appearance on MRI. The most common reported histopathology finding was myxoid degeneration (73.9%) and fibrosis (52.2%). The most common arthroscopic abnormality was fraying (18.2%) and erythema (13.6%). Utilizing histopathology as the gold standard, the two radiologists demonstrated a sensitivity of 35.0% v 42.9%, specificity of 66.7% v 100%, PPV of 87.5% v 100%, and NPV of 13.3% v 14.3%. Corresponding arthroscopic inspection demonstrated a sensitivity of 31.6%, specificity of 66.6%, PPV 85.7% and NPV of 13.3%. There was moderate agreement between the two radiologists, κ = 0.534 (95% CI, 0.177 to 0.891), p = 0.01.

CONCLUSION

Histopathological features of low grade tendinosis including mainly myxoid degeneration and fibrosis are frequently occult on MR imaging.

Regional histologic differences in the long head of the biceps tendon following subpectoral biceps tenodesis in patients with rotator cuff tears and SLAP lesions

PURPOSE

The purpose of this study was to quantify the regional histology of the long head of the biceps tendon (LHBT) and compare the histopathology present to clinical findings in patients with rotator cuff tears and SLAP lesions.

METHODS

Prospectively enrolled patients undergoing an open subpectoral LHBT tenodesis in the setting of a rotator cuff (RTC) tear or SLAP lesion. Perioperative data were collected and the excised LHBT was analyzed by a fellowship trained pathologist. Tendons were sectioned into proximal (biceps anchor), middle (bicipital groove), and distal (myotendinous junction) portions. Sections were stained with Movat's pentachrome stain and digitized for analysis. Comparisons were made between the histologic findings present in the setting of a rotator cuff tear with those seen in the setting of a SLAP tear.

RESULTS

39 tendons were analyzed: 20 from patients with SLAP lesions (mean age of 44.7 years, range 23-60 years) and 19 from patients with rotator cuff tears (mean age of 58.7 years, range 43-71). Patients with the most pathologic tendons in the bicipital groove were significantly older (59.4 vs. 50.4 years; p < 0.05), reported higher pre-operative VAS scores (6.6 vs. 5.0; p < 0.02), and demonstrated lower pre-operative ASES scores (41.6 vs. 50.7; p < 0.05). The RTC group showed significantly more mucinous degeneration at both the proximal (p < 0.03) and the middle (p < 0.01) tendon portions compared to the SLAP group. In both groups, the portions of proximal tendon showed significantly (p < 0.05) more mucinous degeneration than distal portions.

CONCLUSION

Regional histologic differences exist in the LHBT. Rotator cuff patients showed the most degenerated tendon in the bicipital groove and these patients tended to be older and have higher VAS and lower ASES scores. Surgeons should consider performing a subpectoral biceps tenodesis as the bicipital groove portion of the tendon may be very degenerated, especially in patients with rotator cuff disease. Additional research is warranted to distinguish whether treating the biceps differently in distinct geographic regions affects patient outcomes.

LEVEL OF EVIDENCE

II.

The prevalence of rotator cuff pathology in the setting of acute proximal biceps tendon rupture

BACKGROUND

The prevalence and severity of concomitant rotator cuff pathology in the setting of proximal biceps tendon ruptures are poorly understood. Concomitant rotator cuff disease may have important implications in the prognosis and natural history of this shoulder condition. Therefore, an observational cohort of patients with an acute rupture of the long head of the biceps tendon (LHBT) was evaluated to determine the prevalence and severity of concomitant rotator cuff disease.

METHODS

Thirty consecutive patients diagnosed with acute proximal biceps tendon rupture were prospectively enrolled. Magnetic resonance imaging of the affected shoulder was obtained in 27 patients and reviewed by a fellowship-trained orthopedic surgeon.

RESULTS

The cohort consisted of 20 men (74%) and 7 women (26%) (mean age, 61.0 years [range, 42-78 years]). The dominant side was involved in 20 injuries (74%), and a low-energy trauma mechanism of injury was involved in 23 (85%). Of the patients, 11 (41%) reported a history of antecedent shoulder pain. Magnetic resonance imaging assessment revealed that 93% of patients had evidence of rotator cuff disease, including 13 full-thickness tears. Of the full-thickness tears, 3 were small, 6 medium, 2 large, and 2 massive. Pathology of the subscapularis tendon was identified in 7 patients (26%).

CONCLUSION

In this cohort, we found LHBT rupture to be highly correlated with the presence of rotator cuff disease, with the majority of patients presenting with full-thickness tears of the supraspinatus. These findings may have important implications in the treatment and prognosis of patients who present with acute LHBT ruptures.

Fibrocartilaginous metaplasia identified in the long head of the biceps brachii

BACKGROUND

In the glenohumeral joint, the long head of biceps brachii (LHBB) is exposed to tension and compression loading. The short head of biceps brachii (SHBB) works only in tension. It is known that tendon under compression might develop fibrocartilaginous metaplasia that improves the resistance to compression but reduces the resistance to tension. This study evaluated the presence of cartilage in LHBB and SHBB samples, supporting its possible role in tendon tear.

METHODS

Between 2014 and 2016, 13 samples of LHBB and SHBB were collected during surgery for shoulder instability, glenohumeral arthritis, and massive rotator cuff tears. The samples were stained with hematoxylin and eosin, safranin-O, and Alcian blue (pH 1.0) for light microscopy. Immunohistochemistry was performed using anti-S100, anti-collagen I and II, and anti-tenascin-C antibodies.

RESULTS

Histochemistry: LHBB samples showed matrix disorganization, with clusters of chondrocyte surrounded by collagen fibers and glycosaminoglycans. Safranin-O showed evident metachromasia. SHBB samples did not show any matrix disorganization or cartilaginous metaplasia. Immunohistochemistry: In all LHBB samples, anti-S100 and anti-collagen II showed cartilage in proximity of the tendon tear. Tenascin C immunostained closely to the disorganized matrix areas. SHBB, however, showed no positive areas for S-100, anti-collagen II, or tenascin C.

CONCLUSIONS

According to our results, we hypothesize that the repeated stimulation in compression may induce the formation of fibrous cartilage. However, to date its role in tendon pathology remains to be clearly defined.

Radiologic and Histologic Evaluation of Proximal Bicep Pathology in Patients With Chronic Biceps Tendinopathy Undergoing Open Subpectoral Biceps Tenodesis

PURPOSE

To correlate preoperative magnetic resonance imaging (MRI) and intraoperative anatomic findings within the proximal long head biceps tendon to histologic evaluation of 3 separate zones of the tendon in patients with chronic biceps tendinopathy.

METHODS

Sixteen patients with chronic biceps tendinopathy were treated with open subpectoral biceps tenodesis. Preoperative MRI tendon grading was as follows: normal tendon, increased signal, tendon splitting, incomplete/complete tear. The removed portion of the biceps tendon was split into 3 segments: zone 1, 0-3.5 cm from the labral insertion; zone 2, 3.5-6.5 cm; and zone 3, 6.5-9 cm, and was histologically evaluated using the Bonar score. Tenosynovium adjacent to the tendon was assessed histologically using the Osteoarthritis Research Society International score. CD31, CD3, and CD79a immunohistochemistries were conducted to determine vascularization, T-cell infiltrates, and B-cell infiltrates, respectively. Analysis of variance and Pearson correlations were performed for statistical analysis.

RESULTS

Preoperative MRI showed no significant differences in tendon appearance between zones 1-3. Intraoperative findings included nonspecific degenerative SLAP tears or mild/moderate biceps tenosynovitis in all cases. Significantly (P < .001) higher Bonar scores were noted for tendon in zones 1 (7.9 ± 1.8) and 2 (7.3 ± 1.5) compared with zone 3 (5.0 ± 1.1). Cell morphology scores in zone 1 (1.9 ± 0.4) and zone 2 (1.5 ± 0.6) were significantly higher than that in zone 3 (0.8 ± 0.3) (P < .05). Inflammatory tenosynovium showed weak correlation with tendon changes in zone 1 (r = 0.08), zone 2 (r = 0.03), or zone 3 (r = 0.1).

CONCLUSIONS

In patients with chronic long head biceps tendinopathy who underwent open subpectoral tenodesis, MRI and intraoperative assessment did not show significant structural abnormalities within the tendon despite significant histopathologic changes. Severity of tendon histopathology was more pronounced in the proximal and mid-portions of the tendon.

CLINICAL RELEVANCE

Proximal versus distal biceps tenodesis is a subject of frequent debate. This study contributes to the ongoing evaluation of the characteristics of the proximal biceps in this type of pathologic condition.

Histological Changes in Biceps Muscle after Tenotomizing the Biceps Long Head in a Rat Model

Background

Popeye deformity is common after rupture of the biceps muscle’s long head tendon. Herein, we report on histological changes in biceps brachii muscles following tenotomy of the long head biceps tendon.

Methods

Twelve Sprague-Dawley rats (12-week-old) underwent tenotomy of the long head biceps tendon in the right shoulder. At postoperative weeks 4, 7, and 10, the operative shoulders were removed by detaching the biceps brachii muscle from the glenoid scapula and humerus; the opposite shoulders were removed as controls. H&E staining was performed to elucidate histological changes in myocytes. Oil-red O staining was performed to determine fatty infiltration. Myostatin antibody immunohistochemistry staining was performed as myostatin is expressed by skeletal muscle cells during myogenesis.

Results

H&E staining results revealed no changes in muscle cell nuclei. There were no adipocytes detected. Compared with that of the control biceps, the cross-sectional area of the long head biceps was significantly smaller (p=0.00). Statistical changes in the total extent of the 100 muscle cells were significant (p=0.00). Oil-red O staining revealed no fatty infiltration. Myostatin antibody immunohistochemical staining revealed no significant difference between the two sides.

Conclusions

Muscular changes after tenotomy of the long head biceps included a decrease in the size of the individual muscle cells and in relative muscle mass. There were no changes observed in muscle cell nuclei and no fatty infiltration. Moreover, there were no changes detected by myostatin antibody immunohistochemistry assay.

Proximal Long Head Biceps Rupture: A Predictor of Rotator Cuff Pathology

PURPOSE

To investigate whether acute rupture of the proximal long head biceps is a harbinger of disease of the nearby supraspinatus and subscapularis tendons.

METHODS

A retrospective chart review from February 1, 2008, to August 31, 2016, was performed at our institution identifying patients who presented with an acute (<12-week) history of "Popeye" deformity of the distal biceps and a magnetic resonance imaging (MRI) of the affected shoulder. MRI images were then reviewed in duplicate to determine supraspinatus and subscapularis tendon tear incidence, size, chronicity, and depth. The association between rotator cuff status and acute long head biceps rupture as well as patient age, sex, smoking status, hand dominance, and history of diabetes mellitus or trauma was then evaluated.

RESULTS

A total of 116 patients were included in this study (mean age: 61.9 ± 10.9 years). A significant proportion (n = 99; incidence: 85%) were found to have some degree of supraspinatus or subscapularis tendon tearing on MRI (P < .001). These patients were also found to be significantly older compared with those with an intact rotator cuff (mean age 63.3 ± 10.7 vs 54.2 ± 9.2; P = .001). Full thickness rotator cuff tears were significantly more likely to involve the supraspinatus as opposed to the subscapularis (incidence: 44% and 21%; P = .002).

CONCLUSIONS

Despite the expected association of rotator cuff disease with increasing patient age, the results of this study also affirm the hypothesis that inflammation in the rotator cuff interval signaled by rupture of the long head of biceps is a harbinger of rotator cuff disease. Clinicians should have a high index of suspicion regarding concomitant anterosuperior rotator cuff pathology in patients presenting with acute long head of biceps rupture. Early evaluation with advanced imaging should be strongly considered.

LEVEL OF EVIDENCE

Level IV, case series.