The long head of biceps as a source of pain in active population: tenotomy or tenodesis? A comparison of 2 case series with isolated lesions

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

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

Tenodesis yields better functional results than tenotomy in long head of the biceps tendon operations-a systematic review and meta-analysis

BACKGROUND

Pathology of the long head of the biceps tendon (LHBT) is a common disorder affecting muscle function and causing considerable pain for the patient. The literature on the two surgical treatment methods (tenotomy and tenodesis) is controversial; therefore, our aim was to compare the results of these interventions.

METHODS

We performed a meta-analysis using the following strategy: (P) patients with LHBT pathology, (I) tenodesis, (C) tenotomy, (O) elbow flexion and forearm supination strength, pain assessed on the ten-point Visual Analog Scale (VAS), bicipital cramping pain, Constant, ASES, and SST score, Popeye deformity, and operative time. We included only randomized clinical trials. We searched five databases. During statistical analysis, odds ratios (OR) and weighted mean differences (WMD) were calculated for dichotomous and continuous outcomes, respectively, using the Bayesian method with random effect model.

RESULTS

We included 11 studies in the systematic review, nine of these were eligible for the meta-analysis, containing data about 572 patients (279 in the tenodesis, 293 in the tenotomy group). Our analysis concluded that tenodesis is more beneficial considering 12-month elbow flexion strength (WMD: 3.67 kg; p = 0.006), 12-month forearm supination strength (WMD: 0.36 kg; p = 0.012), and 24-month Popeye deformity (OR: 0.19; p < 0.001), whereas tenotomy was associated with decreased 3-month pain scores on VAS (WMD: 0.99; p < 0.001). We did not find significant difference among the other outcomes.

CONCLUSION

Tenodesis yields better results in terms of biceps function and is non-inferior regarding long-term pain, while tenotomy is associated with earlier pain relief.

Disabled Throwing Shoulder 2021 Update: Part 1-Anatomy and Mechanics

The purpose of this article is to provide updated information for sports health care specialists regarding the Disabled Throwing Shoulder (DTS). A panel of experts, recognized for their experience and expertise in this field, was assembled to address and provide updated information on several topics that have been identified as key areas in creating the DTS spectrum. Each panel member submitted a concise presentation on one of the topics within these areas, each of which were then edited and sent back to the group for their comments and consensus agreement in each area. Part 1 presents the following consensus conclusions and summary findings regarding anatomy and mechanics, including: 1) The current understanding of the DTS identifies internal impingement, resulting from a combination of causative factors, as the final common pathway for the great majority of the labral pathoanatomy; 2) intact labral anatomy is pivotal for glenohumeral stability, but its structure does not control or adapt well to shear or translational loads; 3) the biceps plays an active role in dynamic glenohumeral stability by potentiating "concavity compression" of the glenohumeral joint; 4) the ultimate function of the kinetic chain is to optimize the launch window, the precise biomechanical time, and position for ball release to most effectively allow the ball to be thrown with maximum speed and accuracy, and kinetic chain function is most efficient when stride length is optimized; 5) overhead throwing athletes demonstrate adaptive bony, capsular, and muscular changes in the shoulder with repetitive throwing, and precise measurement of shoulder range of motion in internal rotation, external rotation, and external rotation with forearm pronation is essential to identify harmful and/or progressive deficits. LEVEL OF EVIDENCE: Level V, expert opinion.

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

INTRODUCTION

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

HYPOTHESIS

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

MATERIALS AND METHODS

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

RESULTS

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

DISCUSSION

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

CONCLUSION

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

LEVEL OF EVIDENCE

III; case-control.

Subpectoral Biceps Tenodesis Using an All-Suture Anchor

Long head biceps tendon pathology is a substantial contributor to anterior shoulder pain and often requires surgical intervention to offer a return to normal functionality. Surgical treatment options consist of both open and arthroscopic tenodesis or tenotomy of the long head biceps brachii. Several techniques exist for tenodesis and tenotomy of the biceps, although current debate continues regarding which surgical approach is the optimal intervention for symptomatic bicep pathology. In this technical note, we describe a subpectoral biceps tenodesis of the long head bicep tendon using an all-suture anchor. Our technique offers the advantages of using an all-suture anchor that incorporates a self-tensioning mechanism with direct visualization of the tendon during biceps tenodesis and anchor insertion.

Arthroscopic Single-Portal Suprapectoral Biceps Tenodesis With All-Suture Anchor

Tenodesis of the long head of the biceps tendon can be performed through arthroscopic and open techniques with various fixation methods and at different locations on the humerus. Many techniques have been described, with controversy surrounding the advantages and disadvantages of each. In this Technical Note, we describe an all-arthroscopic, intra-articular, single-portal, suprapectoral biceps tenodesis with an all-suture anchor. This technique also allows for suture passage through the biceps tendon before tenotomy to ensure proper maintenance of the length-tension relationship of the biceps musculotendinous unit.

Tenotomy or Tenodesis for Tendinopathy of the Long Head of the Biceps Brachii: An Updated Systematic Review and Meta-analysis

Purpose

The purpose of this meta-analysis was to provide an up-to-date comparison of clinical outcomes of tenotomy and tenodesis in the surgical treatment of long head of the biceps brachii (LHB) tendinopathy.

Methods

A literature search was conducted in EMBASE, Pubmed/Medline and the Cochrane database from January 2000 to May 2020. All studies comparing clinical outcomes between LHB tenotomy and tenodesis were included. Quality was assessed using the Coleman score.

Results

We included 25 studies (8 randomized studies) comprising 2,191 patients undergoing LHB tenotomy or tenodesis, with or without concomitant shoulder procedures (mainly rotator cuff repairs). The Coleman score ranged from 29 to 97 for all studies. When comparing tenodesis and tenotomy in randomized studies, no clinically relevant differences were found in the Constant score (mean difference, 0.9 points), the American Shoulder and Elbow Society Score (mean difference, 1.1 points), shoulder pain (mean difference in visual analogue scale, -0.3 points), elbow flexion strength loss (mean difference, 0%), or forearm supination strength (mean difference, 3%). A Popeye deformity (odds ratio, 0.32) was less commonly seen in patients treated with tenodesis (9% vs 23%).

Conclusion

In our meta-analysis, a Popeye deformity was more frequently observed in patients treated with tenotomy. Based on a substantial number of studies, there is no evidence-based benefit of LHB tenodesis over tenotomy in terms of shoulder function, shoulder pain or biceps-related strength. It is unclear whether LHB tenodesis is of benefit in specific patient groups such as younger individuals.

Level of evidence

Level III, systematic review of level III or higher studies.

Effect of age, gender, and body mass index on incidence and satisfaction of a Popeye deformity following biceps tenotomy or tenodesis: secondary analysis of a randomized clinical trial

BACKGROUND

The purpose of this study was to determine the incidence of Popeye deformity following biceps tenotomy vs. tenodesis and evaluate risk factors and subjective and objective outcomes.

METHODS

Data for this study were collected as part of a randomized clinical trial in which patients aged ≥18 years undergoing arthroscopic shoulder surgery for a long head of the biceps tendon lesion were allocated to undergo tenotomy or tenodesis. The primary outcome measure for this secondary analysis was rate of Popeye deformity at 24 months postoperation as determined by an evaluator blinded to group allocation. Those with a deformity indicated their satisfaction with the appearance of their arm on a 10-cm visual analog scale, rated their pain and cramping, and completed the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form and the Western Ontario Rotator Cuff index. Isometric elbow flexion and supination strength were also measured. Cohen kappa was calculated to measure inter-rater reliability between patient and evaluator on the presence of a deformity. Logistic regression was performed to identify predictors of presence or absence of a Popeye deformity.

RESULTS

One hundred fourteen patients were randomly assigned to 2 groups, of which 42 to the tenodesis group and 45 to the tenotomy group completed a 24-month follow-up. Based on clinical observation, the odds of a Popeye in the tenotomy group were 4.3 times greater than in the tenodesis group (P = .018) with incidence of 33% (15/45) and 9.5% (4/42), respectively. Surgical technique was the only significant predictor of perceived deformity, with male gender trending toward significance (odds ratio 7.33, 95% confidence interval 0.867-61.906, P = .067). Mean (standard deviation) satisfaction score of those with a deformity regarding appearance of their arm was 7.3 (2.6). Increasing satisfaction was correlated with increasing age (r = 0.640, P = .025), but there was no association with gender (r = -0.155, P = .527) or body mass index (r = -0.221, P = .057). Differences in subjective outcomes were dependent on whether the Popeye was clinician- or self-assessed.

CONCLUSION

The odds of developing a perceived Popeye deformity was 4.3 higher after tenotomy compared to tenodesis based on clinician observation. Male gender was trending toward being predictive of having a deformity. Pain and cramping were increased in those with a self-reported Popeye. Younger patients were significantly less satisfied with a deformity despite no difference in functional outcomes at 24 months. Thus, biceps tenodesis may be favored in younger male patients to minimize the risk of Popeye and the risk of dissatisfaction in the appearance of their arm following surgery.

Does Biceps Tenotomy or Tenodesis Have Better Results After Surgery? A Systematic Review and Meta-analysis

BACKGROUND

Although tenotomy and tenodesis are frequently used for long head of the biceps tendon lesions, controversies remain as to which technique is superior regarding pain, functionality, complications, and cosmetic appearance.

QUESTIONS/PURPOSES

(1) For long head of biceps tendon lesions, does tenotomy or tenodesis result in greater improvements in VAS score for pain? (2) Which approach has superior results when evaluating function outcome (Constant) scores? (3) Does tenotomy or tenodesis have fewer complications? (4) Does tenotomy or tenodesis result in better cosmesis (Popeye sign)?

METHODS

A systematic review was performed in the Cochrane Library, Embase, PubMed, and Literatura Latino Americana e do Caribe em Ciências da Saúde (LILACS) using the keywords "long head of the biceps tendon," "biceps tenodesis," and "tenotomy." We completed the search in June 2020. The inclusion criteria were randomized controlled trials and quasirandomized controlled trials that investigated tenodesis and tenotomy with no language restriction and evaluation of adult patients who presented with a long head of the biceps tendon lesion, associated with other lesions or not, without previous shoulder surgeries and who had no response to nonoperative treatment. The initial search yielded 239 studies, 40 of which were duplicates. We assessed the titles and abstracts of 199 articles and excluded all studies that were not randomized controlled trials (literature reviews) or that compared different techniques. We assessed the full text of 14 articles and excluded the ones that were protocols and cohort studies. We evaluated the risk of bias using the Cochrane Collaboration tool. We included eight studies in this systematic review and meta-analysis, with a total of 615 participants, 306 of whom were treated with tenotomy and 309 with tenodesis. The median duration of follow-up was 2 years. Overall, the included studies had a low risk of bias. The complications evaluated were adhesive capsulitis, biceps brachii tear, cramps, and a subsequent second surgical procedure. We used a random model in this meta-analysis so that we could generalize the results beyond the included studies. In this study, we only reported differences between the groups if they were both statistically valid and larger than the minimum clinically important difference (MCID).

RESULTS

Comparing tenotomy and tenodesis, we observed no difference between the groups regarding pain in the long term (mean difference 0.25 [95% confidence interval -0.29 to 0.80]; p = 0.36). There was no difference in Constant score in the long-term (mean difference -1.45 [95% CI -2.96 to 0.06]; p = 0.06). There were no differences when evaluating for major complications (odds ratio 1.37 [95% CI 0.29 to 6.56]; p = 0.70). There were not enough papers evaluating adhesive capsulitis, cramping, and risk of revision surgery. Popeye sign was more frequent in the tenotomy group than in the tenodesis group (OR 4.70 [95% CI 2.71 to 8.17]; p < 0.001).

CONCLUSION

This systematic review demonstrated that tenotomy and tenodesis offer satisfactory treatment for long head of the biceps tendon lesions. In terms of pain improvement and Constant score, there was no difference between the techniques, but patients undergoing tenotomy have worse cosmetic results. Therefore, surgeons should choose the technique based on their skills and the patient's expectations of surgery, such as cosmesis and time to recovery. More studies are needed to evaluate complications such as adhesive capsulitis and cramping, as well as to compare duration of surgery and recovery time for each technique.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Early success of the arthroscopic-assisted locked loop suprapectoral biceps tenodesis

Background

There is wide variability in surgical technique for biceps tenodesis. Prior biomechanical studies have demonstrated superior ultimate and fatigue strength with a Krakow-type locked loop when compared with simple suture and lasso-loop configurations; however, this had not yet been clinically studied. The purpose of this study was to assess the short-term results an arthroscopic-assisted locked loop (ALL) suprapectoral biceps tenodesis technique.

Methods

All patients who underwent an ALL suprapectoral biceps tenodesis by a single surgeon from 2012 and 2019 with a minimum of 12-month follow-up were analyzed. Data collected included demographics, surgical indications, concomitant operative procedures, and postoperative complications of anterior shoulder "groove" pain, "Popeye deformity," biceps muscle cramping pain, and need for revision surgery.

Results

Forty patients who underwent an ALL suprapectoral biceps tenodesis met inclusion criteria. Patients were 55.6 ± 8.6 years of age, consisting of 28 men (57%) and 21 women (43%). The median follow-up was 19.3 months. At the latest follow-up, 1 (2%) patient had anterior shoulder "groove" pain, and no patients had a Popeye deformity or biceps muscle cramping. There were no revision biceps tenodesis procedures.

Conclusion

The ALL suprapectoral biceps tenodesis technique results in a low incidence of postoperative complications. At a short-term follow-up of 1 year, no patients had reoperations or revisions for failed biceps tenodesis. Groove pain was nearly absent in this series of patients.

Biceps tenotomy versus tenodesis for lesions of the long head of the biceps tendon: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Biceps tenotomy and biceps tenodesis are 2 most common surgical procedures for long head of the biceps tendon (LHBT) pathology, but debate still exists regarding the choice of treatment. This meta-analysis was conducted to compare clinical results between tenotomy and tenodesis for the treatment of lesions of LHBT. It was hypothesized that there is no difference in outcomes of tenotomy and tenodesis for lesions of LHBT.

METHODS

A comprehensive search of literature published between 1980 and April 2020 was performed using MEDLINE, EMBASE, Web of Science, and the Cochrane Library databases. Randomized controlled trials (RCTs) comparing tenotomy and tenodesis for LHBT lesions were included. The primary outcomes were Constant score and Popeye deformity. The secondary outcomes included the American Shoulder and Elbow Surgeons (ASES) score, visual analog scale (VAS) for pain, muscle strength, cramping pain, and operative time. For primary outcomes, trial sequential analysis (TSA) was conducted to reduce the risk of random errors and the GRADE (grading of recommendations, assessment, development, and evaluations) approach was used to assess the quality of the body of evidence.

RESULTS

A total of 9 RCTs were included. In pooled analysis, statistical significance was observed in the Constant score (mean difference [MD], 1.59; 95% confidence interval [CI] 0.04-3.14; P = .04), Popeye deformity (risk ratio [RR], 0.33; 95% CI, 0.22-0.49; P < .00001) and operative time (MD, 9.94; 95% CI 8.39-11.50; P < .00001). However, there were no significant differences between the tenodesis and tenotomy in ASES score (P = .71), VAS for pain (P = .79), cumulative elbow flexion strength (P = .85), cumulative elbow supination strength (P = .23), and cramping pain (P = .61) TSA revealed that the results for Constant score was inconclusive.

CONCLUSION

For the treatment of LHBT lesions, with the exception of constant score, there was no significant benefit of tenodesis over tenotomy. Although tenotomy is affected by a higher risk of Popeye sign, it is more timesaving.

Ultrasound-Guided Percutaneous Tenotomy of the Long Head of Biceps Tendon in Patients with Symptomatic Complete Rotator Cuff Tear: In Vivo Non-contRolled Prospective Study

Background: We prospectively tested technical feasibility and clinical outcome of percutaneous ultrasound-guided tenotomy of long head of biceps tendon (LHBT). Methods: We included 11 patients (6 women; age: 73 ± 8.6 years) with symptomatic full-thickness rotator cuff tear and intact LHBT, in whom surgical repair was not possible/refused. After ultrasound-guided injection of local anesthetic, the LHBT was cut with a scalpel under continuous ultrasound monitoring until it became no longer visible. Pain was recorded before and at least six months after procedure. An eight-item questionnaire was administered to patients at follow-up. Results: A median of 4 tendon cuts were needed to ensure complete tenotomy. Mean procedure duration was 65 ± 5.7 s. Mean length of skin incision was 5.8 ± 0.6 mm. Pre-tenotomy VAS score was 8.2 ± 0.7, post-tenotomy VAS was 2.8 ± 0.6 (p < 0.001). At follow-up, 5/11 patients were very satisfied, 5/11 satisfied and 1/11 neutral. One patient experienced cramping and very minimal pain in the biceps. Six patients had still moderate shoulder pain, 1/11 minimal pain, 2/11 very minimal pain, while 2/11 had no pain. No patients had weakness in elbow flexion nor limits of daily activities due to LHBT. One patient showed Popeye deformity. All patients would undergo ultrasound-guided tenotomy again. Conclusion: ultrasound-guided percutaneous LHBT tenotomy is technically feasible and effective.

Surgical treatment for long head of the biceps tendinopathy: a network meta-analysis

BACKGROUND

Surgical options for pathology affecting the long head of the biceps tendon (LHBT) include tenotomy and tenodesis, both of which can be performed with a variety of fixation methods. This study aimed to compare surgical treatment options for LHBT lesions using a network meta-analysis of published clinical studies.

METHODS

A systematic review of the literature was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Clinical studies comparing surgical treatment options for LHBT lesions were included. Postoperative outcomes were compared between surgical treatment options using a frequentist approach to network meta-analysis.

RESULTS

There were 22 studies comparing surgical treatment options for LHBT pathology including arthroscopic tenotomy, arthroscopic suprapectoral tenodesis, arthroscopic intracuff tenodesis, and open subpectoral tenodesis, consisting of 1804 patients. Compared with arthroscopic tenotomy, open subpectoral tenodesis resulted in a significantly greater American Shoulder and Elbow Surgeons score (mean difference, 4.58; P = .014). On the basis of the P-score, all 3 tenodesis techniques ranked above tenotomy with respect to the Constant score. Compared with arthroscopic tenotomy, the incidence of Popeye deformity was reduced with arthroscopic suprapectoral tenodesis (odds ratio [OR], 0.23; P < .001) and open subpectoral tenodesis (OR, 0.25; P = .022). The incidence of bicipital groove pain was increased after arthroscopic intracuff tenodesis (OR, 2.89; P = .021) compared with arthroscopic tenotomy.

CONCLUSION

Lesions of the LHBT treated with open or arthroscopic tenodesis resulted in comparatively superior functional outcomes and a lower incidence of Popeye deformity, whereas arthroscopic intracuff tenodesis resulted in a higher incidence of bicipital groove pain.

SLAP Lesion and Injury of the Proximal Portion of Long Head of Biceps Tendon in Elite Amateur Wrestlers

BACKGROUND

Injuries to the proximal portion of the tendon of the long head of the biceps are challenging, and often only diagnosed at arthroscopy. However, it is important to be able to formulate a preoperative plan based on physical examination and imaging studies, so as to inform patients correctly, plan the likely procedure, and give indication to length and modalities of rehabilitation.

MATERIALS AND METHODS

Eleven elite wrestlers who suffered their injury between 2008 and 2018 were investigated retrospectively. We aimed to identify an association between the mechanism and the symptoms of the biceps-labral complex injury.

RESULTS

The injury was sustained at a mean age of 20.63 years, and most wrestlers were middle or light weight. All injuries occurred during shoulder movements in closed kinetic chain with the elbow extended, the forearm pronated and the shoulder slightly elevated. The surgical procedures performed were tenodesis in three wrestlers, reinsertion in seven wrestlers, and one tenotomy of the tendon of the long head of the biceps. The postoperative rehabilitation was shorter (1-3 month) in case of tenodesis or tenotomy, and markedly longer after reinsertion (6-9 months).

CONCLUSIONS

Injuries to the proximal part of long head of biceps tendon are relatively frequent in elite wrestlers, reflecting the high functional demands imposed on the upper limb. Though necessitating surgery, in these athletes, such injuries are not career ending, and most of our elite athletes returned to high performance levels after surgery.

Biceps Tenodesis Versus Tenotomy in the Treatment of Lesions of the Long Head of the Biceps Tendon in Patients Undergoing Arthroscopic Shoulder Surgery: A Prospective Double-Blinded Randomized Controlled Trial

BACKGROUND

The biceps tendon is a known source of shoulder pain. Few high-level studies have attempted to determine whether biceps tenotomy or tenodesis is the optimal approach in the treatment of biceps pathology. Most available literature is of lesser scientific quality and shows varying results in the comparison of tenotomy and tenodesis.

PURPOSE

To compare patient-reported and objective clinical results between tenotomy and tenodesis for the treatment of lesions of the long head of the biceps brachii.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

Patients aged ≥18 years undergoing arthroscopic surgery with intraoperative confirmation of a lesion of the long head of the biceps tendon were randomized. The primary outcome measure was the American Shoulder and Elbow Surgeons (ASES) score, while secondary outcomes included the Western Ontario Rotator Cuff Index (WORC) score, elbow and shoulder strength, operative time, complications, and the incidence of revision surgery with each procedure. Magnetic resonance imaging was performed at postoperative 1 year to evaluate the integrity of the procedure in the tenodesis group.

RESULTS

A total of 114 participants with a mean age of 57.7 years (range, 34 years to 86 years) were randomized to undergo either biceps tenodesis or tenotomy. ASES and WORC scores improved significantly from pre- to postoperative time points, with a mean difference of 32.3% (P < .001) and 37.3% (P < .001), respectively, with no difference between groups in either outcome from presurgery to postoperative 24 months. The relative risk of cosmetic deformity in the tenotomy group relative to the tenodesis group at 24 months was 3.5 (95% CI, 1.26-9.70; P = .016), with 4 (10%) occurrences in the tenodesis group and 15 (33%) in the tenotomy group. Pain improved from 3 to 24 months postoperatively (P < .001) with no difference between groups. Cramping was not different between groups, nor was any improvement in cramping seen over time. There were no differences between groups in elbow flexion strength or supination strength. Follow-up magnetic resonance imaging at postoperative 12 months showed that the tenodesis was intact for all patients.

CONCLUSION

Tenotomy and tenodesis as treatment for lesions of the long head of biceps tendon both result in good subjective outcomes but there is a higher rate of Popeye deformity in the tenotomy group.

REGISTRATION

NCT01747902 ( ClinicalTrials.gov identifier).

PREVALENCE OF POPEYE DEFORMITY AFTER LONG HEAD BICEPS TENOTOMY AND TENODESIS

Objective:

To evaluate whether body mass index (BMI) 30 can be used as a cut-off point in decisions about whether or not to perform long head biceps (LHB) tenodesis, leading to a low rate of esthetic complaints, and to compare two tenodesis techniques.

Methods:

Ninety-six patients underwent shoulder arthroscopy where tenotomy was performed separately in patients with a BMI ≥30 and was followed by tenodesis when BMI <30. The patients were assessed on the basis of their personal perception of the deformity and by 3 independent observers.

Results:

The patient's perception of esthetic deformity in the arm was 15.6%. In the tenotomy group (12.5%) and in the tenodesis group (17.9%) - (p = 0.476). Patients with rocambole-like tenodesis perceived the deformity in 13.2% of cases, while patients with anchor tenodesis noticed the deformity 27.8% (p = 0.263) of the time. There was no statistical difference in the perception of deformity among the independent examiners.

Conclusion:

BMI 30 can be used as a cut-off point in decisions about whether or not to perform LHB tenodesis, leading to low rates of esthetic complaint by patients (12.5%). The rocambole-like tenodesis technique appears to be more able to avoid esthetic deformity of the arm after the LHB tenotomy according to the patients' observations. Level of evidence II, Prospective comparative study.

Small-incision open distal subpectoral vs. arthroscopic proximal biceps tenodesis for biceps long head tendon lesions with repair of rotator cuff tears

The curative effect of small-incision open distal subpectoral vs. arthroscopic proximal biceps tenodesis for lesions in the long head of the biceps tendon (LHBT) combined with rotator cuff repairs (RCR) has remained controversial. The aim of the present study was to compare the two surgical methods. A total of 71 patients who received surgical treatment for LHBT lesions accompanied by RC tears were analyzed. Following arthroscopic RCR and tendectomy of the affected LHBT, 35 patients underwent small-incision open distal subpectoral tenodesis through a small incision (the subpectoral group), while the remaining 36 patients received arthroscopic proximal tenodesis (the arthroscopic group). The surgery time and intra-operative blood loss were compared between the two groups. In addition, the clinical outcomes were evaluated using scoring systems for the functional assessment of the shoulder joint. The subpectoral group had a shorter surgery time and less intra-operative blood loss than the arthroscopic group (P<0.05). The functional scores of the two groups significantly improved as time passed (P<0.05). The subpectoral group was significantly superior to the arthroscopic group with regard to the American Shoulder and Elbow Surgeons score at 2 weeks post-operatively and visual analog scale score at 2 weeks and 3 months post-operatively (P<0.05). Small-incision open distal subpectoral and arthroscopic proximal tenodesis were demonstrated to effectively improve the function of the shoulder joint and relieve pain caused by LHBT lesions accompanied by RCR. However, small-incision open distal subpectoral tenodesis had the additional advantage of shorter surgery time, less intra-operative bleeding and encouraging early results compared to arthroscopic proximal tenodesis. The study was registered as a clinical trial in the Chinese Trial Registry (no. ChiCTR1800015643).

A biomechanical comparison of two arthroscopic suture techniques in biceps tenodesis: whip-stitch vs. simple suture techniques

BACKGROUND

The aim of this study was to compare the biomechanical performance of whip-stitch (WS) and simple suture techniques (SST) of the long head of the biceps tendon in suprapectoral intraosseous tenodesis with interference screw fixation.

METHODS

A total of 10 paired cadavers (61.1 ± 4.6 years) were randomized to receive WS or SST biceps tenodesis beginning at the musculotendinous junction. Both groups implemented a No. 2 FiberLoop wire and underwent suprapectoral fixation with a polyetheretherketone interference screw at the bicipital grove. A Materials Testing System performed cyclic testing (500 cycles), followed by load to failure at 1 mm/s. Load, displacement, and time were recorded during cyclic and failure testing. A 2-tailed Student's t-test and χ2 analysis were performed for failure load and mode of failure, respectively.

RESULTS

Two SST specimens and 1 WS specimen failed during cyclic loading via tendon rupture at the screw-tendon interface. There was no significant statistical difference in the cyclic displacement after 500 cycles between the WS (12.9 mm ± 4.4 mm) and SST groups (14.0 mm ± 3.8 mm, P = .2); cyclic strain, defined as the peak displacement at the 500th cycle divided by the initial gauge length, between the WS (0.4 ± 0.2) and SST groups (0.7 ± 0.7, P = .3); maximal load (162.7 N ± 56.8 N vs. 153.1 N ± 39.3 N, respectively, P = .6); and stiffness (50.5 N/mm ± 17.7 N/mm vs. 43.3 N/mm ± 10.9 N/mm, respectively, P = .3). All specimens ruptured at the screw-tendon interface.

CONCLUSION

The WS technique can provide equivalent biomechanical performance to the SST in suprapectoral intraosseous biceps tenodesis with interference screw fixation.

Editorial Commentary: Back to Work After Shoulder Biceps Tenodesis!!

Assessing the time and factors influencing return to work after any procedure is very important. It helps in both preoperative counseling of patients and gives them a clear picture of the time needed to get back to work. Very few studies have commented on return to work after shoulder biceps tenodesis. In most patients, average time to return to work approximates 5 months; however, for a specific patient, the time to return to work is quite variable and multifactorial. It is important that future studies also analyze the factors and the time to return to preinjury work status.

Establishing minimal clinically important difference, substantial clinical benefit, and patient acceptable symptomatic state after biceps tenodesis

BACKGROUND

The purposes of this study were to establish thresholds for improvement in patient-reported outcome scores that signify the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) after biceps tenodesis (BT) and to assess patient variables that are associated with these clinically important outcomes.

METHODS

A prospectively maintained institutional shoulder registry was queried for patients undergoing isolated BT between 2014 and 2017. Anchor-based and distribution-based approaches were used to calculate the MCID whereas an anchor-based method was used to calculate the SCB and PASS for the Constant-Murley score, Single Assessment Numerical Evaluation (SANE) score, and American Shoulder and Elbow Surgeons score.

RESULTS

A total of 123 patients who underwent isolated BT were included for analysis. The MCID, SCB, and PASS calculated for the American Shoulder and Elbow Surgeons score were 11.0, 16.8, and 59.6, respectively. For the Constant-Murley score, the calculated MCID and PASS were 3.8 and 19.5, respectively. The MCID, SCB, and PASS calculated for the SANE score were 3.5, 5.8, and 65.5, respectively. The following patient variables were significantly associated with decreased odds of achieving the MCID: workers' compensation status, male sex, and higher preoperative SANE score. Patients with a history of ipsilateral shoulder surgery had significantly reduced odds of achieving SCB. The only factor significantly associated with failing to reach the PASS was workers' compensation status.

CONCLUSION

This study established values for the MCID, SCB, and PASS after BT without concomitant rotator cuff repair. Workers' compensation status, previous shoulder surgery, male sex, and higher preoperative patient-reported outcome measure scores are associated with lower odds of achieving clinically significant improvement after BT.

Biceps tenodesis versus biceps tenotomy for biceps tendinitis without rotator cuff tears

Disorders of the long head of the biceps tendon (LHB) are a well-recognised cause of shoulder pain despite the function of the long head of the biceps remaining poorly understood. There has been a dramatic rise in the number of biceps tenodesis procedures being performed in the last decade. This may partly be attributed to concerns regarding residual cosmetic deformity and pain after biceps tenotomy though there is little evidence to suggest that functional outcomes of tenodesis are superior to biceps tenotomy. Current literature focuses on LHB disorders with concomitant rotator cuff tears. The aim of this review is to discuss the anatomy of the LHB, the pathogenesis of tendinopathy of the LHB, indications of biceps tenodesis and tenotomy and compare the current literature on the functional outcomes of these procedures for LHB disorders in the absence of rotator cuff tears.

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.

Tenodesis is not superior to tenotomy in the treatment of the long head of biceps tendon lesions

PURPOSE

To compare the effectiveness of tenodesis and tenotomy in the treatment of long head of the biceps tendon (LHBT) lesions. The null hypothesis was that there is no difference in functional scores between the tenotomy and tenodesis groups.

METHODS

A total of 69 patients with a combined supraspinatus tear and LHBT lesion aged over 40 years entered this prospective comparative study and were randomly assigned to the arthroscopic LHB tenotomy or tenodesis group. Fifty-five patients (31 in the tenotomy group and 24 in the tenodesis group) were available for the 6- and 24-month post-operative evaluations.

RESULTS

There were no statistically significant differences in post-operative Constant and Murley score, quality of life, pain, and strengths between groups. Higher rates of Popeye's sign were noted 6 and 24 months post-operatively in the tenotomy group compared to tenodesis.

CONCLUSIONS

Although tenotomy is affected by a higher incidence of cosmetic deformity, there is no superiority of arthroscopic tenodesis over tenotomy in the treatment of LHBT lesion as a concomitant procedure to an arthroscopic repair of the supraspinatus tendon in terms of functional outcomes, quality of life, pain, and strength measured 6 and 24 months post-operatively.

LEVEL OF EVIDENCE

I.

Open subpectoral biceps tenodesis in patients over 65 does not result in an increased rate of complications

Background

Long head biceps tendon pathology is a common cause of anterior shoulder pain and is often associated with other shoulder conditions, such as rotator cuff tears and osteoarthritis. It is well accepted that older patients are at increased risk for major and minor peri- and postoperative complications.

The purpose of this study is to investigate patients over 65 years old who underwent subpectoral biceps tenodesis and compare the complication rates of this group to those of patients younger than 65 years old. The hypothesis is, that there would be no difference in complication rates and that clinical outcome scores for patients over 65 were satisfying and showed improvements over time.

Methods

There were 337 patients who underwent open subpectoral biceps tenodesis, between January 2005 and June 2015, 23 were identified as being over the age of 65 with a minimum follow up of 12 months. All patients over the age of 65 were evaluated pre- and postoperatively using Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons (ASES), Constant-Murley (CM) and Single Assessment Numeric Evaluation (SANE). Intraoperative and postoperative adverse events (fracture, infection, wound opening, rupture/failure and neurovascular injuries) related to the tenodesis procedure and to the surgery itself were collected from all 337 patients in a routine postoperative follow-up.

Results

The under 65 group (range 27–64 years) at an average follow up (FU) of 30 months (range 12–91 months) showed a 5.4% (17 out of 314) post-operative complication rate related to the subpectoral tenodesis, whereas the group over 65 (range 65–77 years) at an average follow up of 33 months (range 12–79 months) showed an 8.7% (2 out of 23) complication rate.

Conclusion

This study demonstrates that in patients over the age of 65, biceps tenodesis is a successful procedure when performed for biceps tendinopathy and concomitantly with other surgical procedures of the shoulder, and does not result in an increased rate of complications when compared to a group of patients under the age of 65.

A meta-analysis comparing tenotomy and tenodesis for treating rotator cuff tears combined with long head of the biceps tendon lesions

Purpose

The purpose of this meta-analysis was to assess whether there were differences in the outcomes between tenotomy and tenodesis in treating LHBT lesions combined with rotator cuff repairs.

Methods

Using Medline, Embase, and Cochrane, we searched for articles comparing tenotomy and tenodesis combined with rotator cuff repair which were published before April 2016 with the terms “biceps”, “tenotomy”, “tenodesis”, and “rotator cuff”. The controlled clinical studies that met the inclusion and exclusion criteria were assessed for quality of methodology by utilizing the Coleman score.

Results

On the basis of the inclusion and exclusion criteria, ten articles (903 patients) were included in this meta-analysis. The Coleman score ranged between 40 and 89 in the included studies. The results showed that the incidence of the popeye sign (OR, 2.777, P = 0.000) were higher in tenotomy group compared with tenodesis group when concomitant rotator cuff repair. Statistically significant difference in favor of tenodesis was observed for Constant score (SMD, -0.230, P = 0.025). As for the arm cramping pain, patient satisfaction, VAS score, ASES score and UCLA increased score, the strength and the range of motion, there were no significant differences between tenodesis and tenotomy of the LHBT, corresponding to the currently available results in the literature.

Conclusions

Based on this meta-analysis, both tenotomy and tenodesis are effective in pain relief and function improvement in patients with repairable rotator cuff tears. No significant differences in post-operative functional outcome between tenotomy and tenodesis for the treatment of LHBT lesions were observed except for a lower Constant score and higher risk of Popeye deformity in tenotomy.

Subpectoral Biceps Tenodesis Using an Expanding PEEK Device

In this Technical Note, we describe a method of mini-open long head biceps subpectoral tenodesis. The implant used is a threadless expanding PEEK (polyether ether ketone) interference device that fixes the biceps tendon in a drill hole in the humerus under the inferior border of the pectoralis major tendon. The diameter of the drill hole varies between 6 and 8 mm depending on the width of the tendon. The procedure can be performed through a 3-cm incision centered on the inferior border of the pectoralis tendon. Based on our experience, it is a quick, safe, and reliable tenodesis procedure.

The Effect of Concomitant Biceps Tenodesis on Reoperation Rates After Rotator Cuff Repair: A Review of a Large Private-Payer Database From 2007 to 2014

PURPOSE

To determine if reoperation rates are higher for patients who underwent isolated rotator cuff repair (RCR) than those who underwent RCR with concomitant biceps tenodesis using a large private-payer database.

METHODS

A national insurance database was queried for patients who underwent arthroscopic RCR between the years 2007 and 2014 (PearlDiver, Warsaw, IN). The Current Procedural Terminology (CPT) 29,827 (arthroscopy, shoulder, surgical; with RCR) identified RCR patients who were subdivided into 3 groups-group 1: RCR without biceps tenodesis; group 2: RCR with concomitant arthroscopic biceps tenodesis (CPT 29827 and 29,828); group 3: RCR with concomitant open biceps tenodesis (CPT 29827 and 23,430). Reoperation rates (revision RCR, subsequent biceps surgeries) and complications at 30 days, 90 days, 6 months, and 1 year were analyzed. Multivariate logistic regression was used to compare reoperations and complications between groups. Rotator cuff tear size, whether the biceps was ruptured and whether a biceps tenotomy was performed, was not available.

RESULTS

Group 1: 27,178 patients. Group 2: 4,810 patients. Group 3: 1,493 patients. More patients underwent concomitant arthroscopic than concomitant open tenodesis (P < .001). A total of 2,509 patients underwent a reoperation for RCR or biceps tenodesis within 1 year after RCR. When adjusted for age, sex, and comorbidities, no significant differences in reoperation rates at 30 days or 90 days among the 3 groups, but significantly more patients who had a tenodesis, required a reoperation compared with those who did not have a tenodesis at 6 months and 1 year (both P < .001). Urinary tract infections were more common in patients who did not have a tenodesis, whereas dislocation, nerve injury, and surgical site infection were more common in tenodesis patients.

CONCLUSIONS

Higher reoperation rates at 1 year were seen in patients who had concomitant biceps tenodesis.

LEVEL OF EVIDENCE

Level III, case-control database review study.

Subpectoral Biceps Tenodesis for Tenosynovitis of the Long Head of the Biceps in Active Patients Younger Than 45 Years Old

PURPOSE

The objective of this study was to assess the outcomes after subpectoral biceps tenodesis (BT) for long head of the biceps (LHB) tenosynovitis in active patients <45 years old.

METHODS

This was an Institutional Review Board-approved, retrospective outcomes study with prospectively collected data. Patients treated with subpectoral BT were included if they met the following criteria: age <45 years, anterior shoulder pain with arthroscopically confirmed LHB tenosynovitis, no concomitant procedures other than debridement and decompression procedures, and minimum 2 years out from surgery. Patients were excluded from analysis if they refused participation. The American Shoulder and Elbow Surgeons (ASES), Short Form-12, Quick Disabilities of the Arm, Shoulder and Hand, Single Assessment Numeric Evaluation, and pain scores as well as sports participation preoperatively and at a minimum of 2 years postoperatively were obtained. Pre- and postoperative scores were compared using paired samples t-test and Wilcoxon signed-rank test.

RESULTS

Thirty patients met the inclusion criteria. Two of these patients refused to participate in follow-up and were excluded from analysis. Of the remaining 28 patients (17 male, 11 female; 37.0 ± 8.0 years), minimum 2-year outcomes were available for 24 (13 males, 11 females: 37.7 ± 8.2 years; 85.7%). Mean follow-up was 3.1 years (range, 2.0 to 7.3 years). There were significant improvements in all outcome measures including ASES score (P < .001), with a postoperative mean of 95.8 ± 7.8, visual analog scale "pain today" (P < .001), and pain affecting activities of daily living (P < .001). Seventeen of 20 (85%) patients who answered the question about postoperative sport participation were able to return to sport. Mean patient satisfaction was 9.2/10 (standard deviation, +1.7). There were no postoperative complications such as Popeye deformity or cramping. There were no clinical failures.

CONCLUSIONS

Subpectoral BT is an excellent treatment option for active patients <45 years old with LHB tenosynovitis and chronic anterior shoulder pain, resulting in decreased pain, improved function, high satisfaction, and improved quality of life.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Patient Satisfaction After Biceps Tenotomy

Background:

Biceps tenotomy and tenodesis are frequently performed for proximal biceps lesions; however, there continues to be debate as to which method is superior. This study examined patient-reported outcomes after biceps tenotomy.

Hypothesis:

Biceps tenotomy in the setting of concomitant shoulder pathology is a reasonable option with high satisfaction rates and a low incidence of pain and cramping in middle-aged to older individuals.

Study Design:

Case series; Level of evidence, 4.

Methods:

A total of 104 patients (mean age, 63.5 years; range, 40-81 years) were evaluated at the time of surgery and at a mean follow-up of 38.4 months (range, 22-57 months). Biceps tenotomy was performed as a component of more extensive shoulder surgery in all patients. Patient satisfaction, frequency of cramping and spasms, biceps pain, weakness, and cosmetic deformity were evaluated at over 1-year follow-up.

Results:

Ninety-one percent of patients were satisfied or very satisfied with their surgical outcome, and 95% would have their surgery again. Three patients who reported being unsatisfied or very unsatisfied had either advanced glenohumeral arthritis or an irreparable rotator cuff tear. Cosmetic deformity occurred in 13% of patients. Twenty percent reported spasms and cramping in their biceps, and 19% reported some biceps pain; however, frequency of spasms and cramping was typically once weekly, and biceps pain was reported as severe or very severe in only 2 patients. Subjective biceps weakness was reported in 17% of patients. Age had no effect on outcome measures, and female sex was associated with less limitation and greater satisfaction after tenotomy compared with men.

Conclusion:

Our results indicate that patient-reported downsides to biceps tenotomy were usually mild and/or infrequent and did not affect patient satisfaction. We conclude that biceps tenotomy is a viable option that can lead to a high rate of patient satisfaction and outcomes in middle-aged to older individuals undergoing shoulder surgery with biceps pathology.

Tenotomy or tenodesis for pathology of the long head of the biceps brachii: a systematic review and meta-analysis

PURPOSE

The objective of this meta-analysis is to compare clinical outcomes of tenotomy and tenodesis in the surgical treatment of long head of the biceps brachii (LHB).

METHODS

A literature search was conducted in Embase and PubMed from 2000 to April 2014. All studies comparing the clinical outcomes between LHB tenotomy and tenodesis were included. The quality assessment was done by utilizing the Coleman score. We included nine studies comprising 650 patients undergoing LHB tenotomy or tenodesis, mostly with concomitant shoulder pathology.

RESULTS

No significant difference in post-operative Constant score (mean difference 1.77), elbow flexion strength (mean difference 0), and forearm supination strength (mean difference 0.01) in favour of tenodesis was observed. A Popeye deformity (odds ratio 0.17) and cramping pain (odds ratio 0.38) in the bicipital groove muscle were less frequently seen in patients treated with tenodesis. The Coleman score ranged between 45 and 100 in the included studies.

CONCLUSION

Based on this meta-analysis, no differences in post-operative functional outcome between tenotomy and tenodesis for the treatment of LHB lesions were observed. A Popeye deformity and cramping pain in the bicipital groove are more frequently observed in patients treated with tenotomy.

LEVEL OF EVIDENCE

IV.

Patients Have Strong Preferences and Perceptions for Biceps Tenotomy Versus Tenodesis

PURPOSE

To evaluate what factors are important in the patients' preference and their perception of a successful surgical outcome.

METHODS

A biceps-specific questionnaire was developed using a series of questions assessing current symptoms, previous knowledge of biceps tendon surgery, surgical outcome priorities, and patient demographics and administered to 100 patients with proximal biceps pathology after approval by the Institutional Review Board. The patients were asked which surgery they would prefer. A set of χ² tests were used to test the association between categorical variables. All tests were 2-sided and considered significant at P < .05.

RESULTS

A total of 100 patients enrolled in the study, with 49 female and 51 male patients at an average age of 49 years (range, 19 to 79 years). Of the 100 patients, 64 (64%) chose to have biceps tenodesis. Factors predictive of choosing a biceps tenodesis included female sex, and concern of cosmetic deformity and residual postoperative pain with a tenotomy (P < .05). Factors predictive of choosing a tenotomy included male sex, high level of current biciptal groove pain, and concerns regarding the use of additional hardware and longer recovery with a tenodesis (P < .05). Age, body mass index, occupation, income level, and concerns regarding postoperative strength and muscle cramping were not found to have a significant predictive effect toward either procedure.

CONCLUSIONS

Patient age should not be used as the sole criterion when deciding between biceps tenotomy and tenodesis. Our results can be consolidated to 5 predictive, reliable questions that will assist orthopaedic surgeons in making individualized patient-specific decisions regarding proximal biceps tendon surgery by emphasizing what factors are most important to patients for a successful surgical outcome.

The role of tendon and subacromial bursa in rotator cuff tear pain: a clinical and histopathological study

PURPOSE

To evaluate a possible association of shoulder pain with the clinical features and the histopathological changes occurring in the ruptured tendon and subacromial bursa of patients with rotator cuff tear.

METHODS

One hundred and eighty patients were clinically evaluated with the constant score and the visual analogue pain scale. Radiographs and MRI were performed. The chronology of the rupture, the muscle fatty degeneration according to Goutallier's scale and the tear size were evaluated. For each patient, a biopsy of the supraspinatus tendon and subacromial bursa was performed during arthroscopic rotator cuff tear repair and the specimens were histopathologically analysed.

RESULTS

Clinically, the shoulder was more painful in females, in the presence of a chronic cuff lesion and a low Goutallier's grade (P < 0.05). No association was found between pain and age of the patient and between pain and tear size. Histologically, hypertrophy and inflammation of the tendon and hypertrophy, inflammation, oedema and necrosis of the subacromial bursa were directly associated with pain (P < 0.05). Pain decreased significantly in the presence of fatty metaplasia and necrosis of the tendon (P < 0.05).

CONCLUSIONS

This study defines the main clinical and histopathological features of painful rotator cuff tear. In particular, a greater association of pain was observed with the histopathological changes in the bursa compared with those in the rotator cuff. Considering that the bursa plays also an essential role during the healing process, this "new" role of the subacromial bursa as pain generator has important repercussions in both pharmacological and surgical treatments of rotator cuff tears.

LEVEL OF EVIDENCE

IV.

Ultrasound-Guided Percutaneous Tenotomy of Biceps Tendon: Technical Feasibility on Cadavers

We tested the technical feasibility of ultrasound-guided percutaneous tenotomy of the long head of the biceps tendon (LHBT) in cadavers. Both shoulders of two fresh cadavers were scanned anteriorly to evaluate the extra-articular portion of the LHBT. Under ultrasound monitoring, a scalpel was advanced obliquely up to touch the superficial medial side of the LHBT, cutting it until the tendon was not visible anymore. Ultrasound evaluation was repeated after the procedure, and anatomic dissection was performed. The procedure was 100% feasible: four cuts were made to completely sever the tendon; the duration was less than 1 min. Skin incision measured 5 mm in two cases and 6 mm in two cases. Anatomic dissection confirmed complete tendon cut in all cases with proximal and distal tendon stumps very close to each other. Ultrasound-guided percutaneous LHBT tenotomy was 100% technically feasible in cadavers with a quick procedure and minimal cutaneous incision.

Outcomes following long head of biceps tendon tenodesis

Lesions of the proximal long head of the biceps tendon (LHB) have been considered as a major cause of shoulder pain and dysfunction. The role of the LHB in causing pain has been a source of controversy for many years, and extensive literature is available discussing anatomy, function, pathology, and most importantly appropriate treatment. Despite this, there is a lack of consensus in the literature regarding the management of biceps-related pathology. Biceps tenotomy and tenodesis are common surgical treatment options when dealing with LHB-related pathology. In this review, a brief discussion on surgical options is provided while focusing on the different options for biceps tenodesis including outcomes and complications.

Long head BIceps TEnodesis or tenotomy in arthroscopic rotator cuff repair: BITE study protocol

Background

Optimal treatment of the diseased long head of the biceps (LHB) tendon during rotator cuff repair remains a topic of debate: tenotomy or tenodesis. A recent meta analysis revealed no difference in strength or functional outcome between treatments. The included studies varied in methodological quality, and only two were randomized controlled trials (RCTs). As strong evidence in favor of either tenotomy or tenodesis is still lacking, we designed this randomized controlled trial to compare functional outcomes after tenotomy and tenodesis when performed in adjunct to arthroscopic rotator cuff repair.

Methods

Patients older than 50 years with a supraspinatus and/or infraspinatus tendon rupture sized smaller than 3 cm, who are encountered with LHB pathology, will be randomized to either LHB tenotomy or LHB tenodesis. Clinical and patient-reported data will be collected pre-operatively, 6 weeks, 3 months and 1 year after surgery.

Primary outcome is overall shoulder function evaluated with the Constant score at 1 year after surgery. As additional measures of shoulder function, two patient reported outcomes (the Dutch Oxford Shoulder Test and the Disabilities of the Arm Shoulder and Hand questionnaire) will be assessed. Other evaluations include cosmetic appearance evaluated by the “Popeye” deformity, elbow flexion strength, arm cramping pain, MRI-based location of the biceps tendon, quality of life, and duration of surgery. To detect non-inferiority with a one-sided, two-sample t-test with 80 % power and a significance level (alpha) of 0.025, the required sample size is 98 patients.

Discussion

Treatment of LHB tendon lesions is performed differently around the world and meta analyses do not provide conclusive evidence in favor of one of these treatments. This study will strengthen evidence on the risks and benefits of LHB tenotomy and tenodesis in adjunct to a rotator cuff repair, which is important for managing patient expectations.

Trial registration

Dutch Trial Register (NTR3255) January 12, 2012, ClinicalTrials.gov (ID NCT02655848) January 14, 2016, retrospectively registered.

Biomechanical properties of tenotomy versus biceps knot in a cadaver model

BACKGROUND

Biceps tenotomy and biceps tenodesis are the primary methods of treating biceps pathology. This study describes a new technique of tenotomy with the goal of autotenodesis to give the biceps a higher load to failure and decreased chance of a Popeye deformity.

PURPOSE

The purpose of this study was to evaluate the strength of the "biceps knot", which is an outlet tenodesis of the biceps tendon and compare the biomechanical properties of this technique to tenotomy.

METHODS

Ten matched cadaver shoulder pairs were used. In the tenotomy group, an arthroscopic tenotomy was performed at the labral biceps junction using a narrow angled biter. For the biceps knot group, a self-retrieving suture passing device was used to pass a suture as far lateral as possible. The suture was passed from just distal to the biceps insertion on the superior labrum and tied with a standard non-sliding arthroscopic knot. The humerus and biceps tendon were rigidly fixed to a materials testing machine and cyclically loaded at 10-20 N for 100 cycles at 1 Hz. After cyclic testing, a 2 N preload was placed on the tendon and the tendon was pulled in line with the bicipital groove until failure.

RESULTS

The peak load to failure for the biceps knot was 58.9 N (SEM 8.2 N) and 37.3 N (SEM 4.6 N) for the tenotomy group (p = 0.046). The average stiffness for the biceps knot group was 4.2 N/mm (SEM 0.4 N/mm) and 3.2 N/mm (SEM 0.2 N/mm) for the tenotomy group (p = 0.031).

CONCLUSION

Performing the biceps knot is a quick, easy and cost effective alternative to the current tenodesis options available.

Surgical indications for long head biceps tenodesis: a systematic review

PURPOSE

Tenodesis as a treatment for a symptomatic long head of biceps (LHB) tendon is becoming more prevalent and new techniques exist which are purported to make the procedure faster and more effective. The determination of appropriate surgical indications for the procedure will facilitate proper analysis and comparisons of the varied techniques. This review analyses the reported indications in the literature in an attempt to guide future research and treatment.

METHODS

The EMBASE and MEDLINE databases were searched to identify surgical studies that report indications for LHB tenodesis. After title, abstract searches, and full-text reviews, 39 studies were included. Study information was extracted including author, publication date, patient numbers, patient age, follow-up period, procedure performed, surgical indications, and study design.

RESULTS

Although indications were variable and often non-descriptive, of the 39 included studies, the most common indications for LHB tenodesis were partial tearing (51 %), instability (49 %), or tenosynovitis (44 %), SLAP tear (28 %), and positive clinical exam for LHB pain (26 %). Most studies were of low quality of evidence, such as case series (33.0 %) and retrospective studies (43.5 %), and were of low-to-moderate methodological quality.

CONCLUSION

Although indications used for LHB tenodesis are inconsistently reported, the most common indications include LHB tearing, instability, and tenosynovitis. Other indications include clinical exam indicating LHB pathology, SLAP tears and subjective shoulder pain. Rigorous reporting of indications and preoperative/operative findings should be emphasized in future studies, allowing surgeons to appropriately analyse outcomes of LHB tenodesis of different techniques within patient groups with distinct indications.

LEVEL OF EVIDENCE

Systematic review, Level IV.

Pathophysiological Concepts and Treatment of Camptocormia

Camptocormia is a disabling pathological, non-fixed, forward bending of the trunk. The clinical definition using only the bending angle is insufficient; it should include the subjectively perceived inability to stand upright, occurrence of back pain, typical individual complaints, and need for walking aids and compensatory signs (e.g. back-swept wing sign). Due to the heterogeneous etiologies of camptocormia a broad diagnostic approach is necessary. Camptocormia is most frequently encountered in movement disorders (PD and dystonia) and muscles diseases (myositis and myopathy, mainly facio-scapulo-humeral muscular dystrophy (FSHD)). The main diagnostic aim is to discover the etiology by looking for signs of the underlying disease in the neurological examination, EMG, muscle MRI and possibly biopsy. PD and probably myositic camptocormia can be divided into an acute and a chronic stage according to the duration of camptocormia and the findings in the short time inversion recovery (STIR) and T1 sequences of paravertebral muscle MRI. There is no established treatment of camptocormia resulting from any etiology. Case series suggest that deep brain stimulation (DBS) of the subthalamic nucleus (STN-DBS) is effective in the acute but not the chronic stage of PD camptocormia. In chronic stages with degenerated muscles, treatment options are limited to orthoses, walking aids, physiotherapy and pain therapy. In acute myositic camptocormia an escalation strategy with different immunosuppressive drugs is recommended. In dystonic camptocormia, as in dystonia in general, case reports have shown botulinum toxin and DBS of the globus pallidus internus (GPi-DBS) to be effective. Camptocormia in connection with primary myopathies should be treated according to the underlying illness.

The Clinical Impact of Bicipital Tunnel Decompression During Long Head of the Biceps Tendon Surgery: A Systematic Review and Meta-analysis

PURPOSE

(1) To identify existing outcomes studies and (2) to use meta-analysis techniques to summarize pooled clinical outcomes for surgical techniques that decompress the bicipital tunnel and those that do not, to identify important areas for future clinical investigation.

METHODS

A systematic review of the PubMed database was performed in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. Patients were categorized into 2 groups for analysis. Group 1, the "tunnel decompressed" group, included open subpectoral tenodesis, long head of the biceps tendon transfer procedures, and proximal tenodesis techniques that explicitly released the bicipital sheath. Group 2, the "tunnel not decompressed" group, included proximal tenodesis techniques and tenotomy. Validated clinical outcome measures (Constant; University of California, Los Angeles; Simple Shoulder Test; visual analog scale for pain; and American Shoulder and Elbow Surgeons) and revision rates were summarized using inverse-variance weighting in a random-effects model. Because the constituent studies were largely single-cohort observational studies, direct between-group statistical comparisons could not be made.

RESULTS

Thirty studies (comprising 1,881 patients) met the inclusion and exclusion criteria. The Constant score was the most commonly reported outcome measure (16 cohorts, 961 patients) and was seemingly higher in group 1 (88.3 v 81.7). Revision rates; University of California, Los Angeles scores; Simple Shoulder Test scores; visual analog scale scores for pain; and American Shoulder and Elbow Surgeons scores appeared to be similar between groups. The mean patient age was 50.7 ± 5.7 years for group 1 and 58.9 ± 6.3 years for group 2. The Egger intercept method showed an intercept of -13.29 (P < .001) for the Constant score, indicating a high likelihood of publication bias in the included studies.

CONCLUSIONS

Bicipital tunnel-decompressing techniques showed apparently higher Constant scores compared with non-decompressing techniques but may have been affected by differences in mean patient age between groups. Existing literature consists of largely single-cohort retrospective observational Level IV studies, which are likely influenced by significant publication bias.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II through IV studies.

Rupture of the Long Head of the Biceps Tendon in a Pediatric Athlete: A Case Report

CASE

We report a case of an adolescent athlete who sustained an isolated rupture of the long head of the biceps tendon and was subsequently treated with subpectoral biceps tenodesis.

CONCLUSION

Provided that there is no damage to the rotator cuff, an open biceps tenodesis may be performed in this young patient population with good short-term outcomes and return to full activity.

Our Totally Intra-Articular "Needle-Anchor" Tenodesis Technique Applied in Isolated Long Head of the Biceps Tendinopathy: Clinical and Functional Results in 60 Patients

BACKGROUND

The disorders of the long head of the biceps (LHB) are a common cause of shoulder pain. Among all surgical treatments used to resolve LHB tendon disorders, tenodesis is one of the most frequent.The literature describes many arthroscopic and open surgical techniques, but there is still no general consensus on the standard of care.The purpose of this paper is to describe the clinical and functional outcomes of our totally intra-articular "Needle-Anchor" arthroscopic tenodesis technique applied to isolated LHB tendinopathy.

MATERIALS AND METHODS

We present a case study of 60 patients with an isolated LHB tendon disorder, treated with our totally intra-articular Needle-Anchor arthroscopic technique between 2011 and 2013.All patients were assessed preoperatively with University of California, Los Angeles (UCLA) and Constant-Murley (CS) shoulder scores and the visual analogue scale (VAS) for subjective pain assessment. Imaging studies were performed through magnetic resonance imaging. Patients were reevaluated with a follow-up at 3 and 12 months with VAS, UCLA, and CS scores.Statistical analysis was performed with the Mann-Whitney score where values of P<0.05 were considered as significant.

RESULTS

CS showed a significant (P<0.05) improvement at 3 and 12 months follow-up, 81.54 ± 7.5 and 88.90 ± 5.2, respectively; when compared with preoperative values of 55.14 ± 9.8.Moreover, the UCLA score showed significant improvement (P<0.05) at the same follow-ups with values of 28.49 ± 2.1 and 30.88 ± 1.7, respectively, with preoperative scores of 14.03 ± 2.4.VAS values were significant at both follow-ups, 2.54 ± 0.2 and 0.58 ± 0.08, respectively, when compared with preoperative values of 5.34 ± 0.3.

CONCLUSIONS

Biceps tenodesis performed with our Needle-Anchor technique applied to selected patients affected by isolated LHB pathology demonstrated to be effective both in terms of pain and functionality. Moreover, the described technique proved to be reliable, safe, time efficient, easily reproducible, and preserving cosmesis.

Systematic Review of Biceps Tenodesis: Arthroscopic Versus Open

PURPOSE

We present a systematic review of the recent literature regarding the use of arthroscopic and open methods of tenodesis for lesions of the long head of the biceps brachii and present an analysis of the subjective and objective outcomes after these 2 procedures.

METHODS

PubMed was carefully reviewed for suitable articles relating to biceps tenodesis, both open and arthroscopic. We included studies reporting on the clinical outcomes of these 2 procedures that were of Level I to IV evidence and were published in the English language. The primary clinical outcomes for each study were determined, normalized, and reported as the percentage of good or excellent results versus poor results based on the outcome scores and criteria laid out by the authors in each of the studies. The exclusion criteria included studies in which biceps tenodesis was performed in patients with concomitant rotator cuff repairs, nonhuman studies, and biomechanical studies.

RESULTS

A total of 16 studies met our inclusion criteria. Among all studies, a total of 205 arthroscopic tenodesis procedures and a total of 271 open tenodesis procedures were performed. Among the 271 open tenodesis patients, 98% had a good or excellent outcome, with a poor outcome in 5 patients (2%). Among the 205 patients who underwent arthroscopic tenodesis, 98% had a good or excellent outcome, with a poor outcome in 5 patients (2%).

CONCLUSIONS

Both open and arthroscopic biceps tenodesis provided satisfactory outcomes in most patients, and there were no identifiable differences in this review.

Accuracy of magnetic resonance imaging in detecting biceps pathology in patients with rotator cuff disorders: comparison with arthroscopy

BACKGROUND

There is limited information on the validity of magnetic resonance imaging (MRI) in detection of biceps disease. The purpose of this study was to examine the measurement properties of noncontrasted MRI in diagnosis of biceps disease using arthroscopic surgery as the "gold standard."

MATERIALS AND METHODS

Prospectively collected surgical data of patients with impingement syndrome or rotator cuff tear, with biceps disease (study group) or without biceps disease (control group), were reviewed. MRI reports of radiologists with fellowship training in musculoskeletal imaging were retrospectively reviewed and compared with surgical findings.

RESULTS

Data of 183 (130 study and 53 control) patients (73 women [40%], 110 men [60%]; mean age, 62 years [standard deviation, 9]) who had undergone arthroscopic rotator cuff-related surgery during a period of 11 years were used for analysis. Sensitivity and specificity of MRI for detection of full tears of the biceps tendon were 0.54 and 0.98, respectively. Sensitivity and specificity were 0.27 and 0.86 for partial tears of the biceps tendon, respectively. For biceps subluxation or dislocation, sensitivity was 1.00 and specificity was 0.83. The areas under the receiver operating characteristic curves, which quantify the overall accuracy of the tests, were 0.57, 0.75, and 0.92 for partial tear, full tear, and instability of the biceps tendon, respectively.

CONCLUSIONS

Noncontrasted MRI has a low sensitivity and high specificity for detection of full-thickness tears of the biceps tendon. It is highly sensitive for diagnosis of instability of the long head of the biceps. However, its usefulness for diagnosis of partial tears of the biceps tendon remains limited.

Regional mechanical properties of the long head of the biceps tendon

BACKGROUND

Long head of the biceps tenodesis reliably relieves pain, and restores strength, stability, and normal appearance of the upper extremity in the event of biceps tendinopathies. Regional differences in tendon mechanics may provide surgeons with valuable guidance in the placement of the tenodesis repair construct. The purpose of this study was to compare the mechanical properties of the long head of the biceps tendon in three functional regions of the tendon: intra-articular (proximal), suprapectoral (middle), and subpectoral (distal).

METHODS

Uniaxial tensile tests were performed on the long head of the biceps tendon segments to quantify the material and structural properties of the tendon. Material properties were obtained using dogbone-shaped specimens while structural properties were obtained using intact specimens where the clamp boundary conditions simulated the common "gold standard" tenodesis, the interference screw.

FINDINGS

Elastic modulus for the supra- and subpectoral regions were significantly greater than the intra-articular region (P≤0.048). The tensile strength of the subpectoral region tended to be lower compared to all other functional regions (P=0.051). The failure mechanism for intact specimens was similar to that seen for interference screw fixation where tissue failure occurs due to tearing at the bone/tendon/screw interface.

INTERPRETATION

The higher tensile strength of the suprapectoral region compared to the subpectoral region may make this a more desirable location for tenodesis placement based on tissue strength. Similar elastic moduli and structural stiffness between the supra- and subpectoral regions indicate that the construct type may play a bigger role in functional outcomes in relation to construct deformation.