Biceps tenotomy versus tenodesis: clinical outcomes

Repair of Isolated Subscapularis Tears With Concurrent Biceps Tenodesis Using a Single Anchor Results in Satisfactory Clinical Outcomes: Minimum 2-Year Follow-Up

PURPOSE

To investigate the clinical outcomes of patients treated with isolated subscapularis tear repair and biceps tenodesis using a single anchor.

METHODS

Patients diagnosed with subscapularis tear and who underwent arthroscopic surgery by a single surgeon between February 2017 and January 2022 were evaluated retrospectively. Inclusion criteria were patients who underwent repair of isolated subscapularis tear along with tenodesis for long head of the biceps tendon pathologies such as SLAP lesion, instability, partial tear, or tenosynovitis, with a minimum follow-up of 24 months. Assessment included active and passive range of motion, single-assessment numeric evaluation (SANE), visual analog scale (VAS), Constant-Murley score (CMS), and specific subscapularis and biceps tests. Improvements were analyzed using minimum clinically important difference (MCID) values.

RESULTS

A total of 20 patients were included. The mean age was 48.5 ± 7 years, and the follow-up period was 43.1 ± 12.7 months. Significant improvements were observed at the final follow-up in active forward flexion, active abduction, active internal rotation, as well as VAS, SANE, and CMS (P < .001). The MCID analysis showed that 100% of patients met the MCID for CMS, 90% for SANE, and 100% for VAS.

CONCLUSIONS

In the presence of an isolated subscapularis tear associated with long head of the biceps tendon pathologies, favorable clinical outcomes could be achieved by performing both tear repair and biceps tenodesis with a double-loaded single anchor. Most patients (>90%) achieved the MCID for the CMS, SANE, and VAS, indicating significant clinical improvement and satisfactory patient outcomes.

LEVEL OF EVIDENCE

Level IV, case series.

Knotted single lasso loop has a lower stiffness and comparable ultimate failure strength compared with knotless whipstitch fixation in onlay tenodesis

BACKGROUND

Suture and knotless anchor onlay tenodesis are two common treatments for biceps lesions; however, there is a paucity of biomechanical studies evaluating the efficacy and structural integrity of these techniques.

METHODS

Tendons were harvested from four lower extremity fresh cadaver specimens, including the extensor digitorum longus, peroneus longus, peroneus brevis, and anterior tibialis tendons. Each tendon diameter was recorded using a digital Vernier caliper. Sixteen 3D printed proximal humeri models were allocated to either the single lasso loop with suture anchor (SLL) group or the whipstitch with knotless suture anchor (WSA) group. Each tenodesis model was initially tested on an electrodynamic material testing instrument under a cyclic load ranging from 5 to 70 N at a speed of 1.25 mm/s. The force on the tendon was then returned to 5 N, which was pulled until the ultimate failure of the construct. Displacement during cyclic loading, ultimate failure load, stiffness, and failure modes were assessed.

RESULTS

Fourteen tenodesis models were validated, and two models were discarded due to technical errors. No significant differences between the two groups were observed regarding tendon diameter, ultimate failure load, and displacement at ultimate failure load. However, the construct stiffness for the SLL group was lower than that of the WSA group (58.02 ± 5.62 N/mm vs. 72.24 ± 15.63 N/mm, P = 0.043).

CONCLUSION

The SLL group had a lower construct stiffness than the WSA group, whereas construct displacement and ultimate failure load were similar in both groups. Therefore, SLL biceps tenodesis may offer a convenient alternative, with lower tendon migration fixation, while performing an arthroscopic biceps tenodesis.

LEVEL OF EVIDENCE

Basic Science Study.

The impact of biceps tenotomy/tenodesis on Popeye sign incidence and functional outcome

Background

Literature reports varied incidences and clinical relevance of Popeye's sign in patients who underwent biceps tenotomy or tenodesis. There is no consensus according to indication and outcome. We aimed to evaluate the frequency of the Popeye sign in a large cohort of patients concomitantly treated with an arthroscopic rotator cuff repair (ARCR). We assessed the effect on the clinical outcome based on biceps tendon treatment and Popeye sign.

Methods

A cohort of 973 primary ARCR patients from different Swiss and German orthopedic clinics was prospectively documented for up to 24 months postoperatively. All patients who received biceps tendon treatment were included in this study. We assessed Popeye sign occurrence across groups treated either with tenodesis or tenotomy. Additionally, we compared clinical and radiological outcome between Popeye/non-Popeye and tenotomy/tenodesis groups.

Results

Eight hundred patients were evaluated, of which 55% (n = 442) underwent tenodesis and 45% (n = 358) received tenotomy of the long head of the biceps tendon. Mean age of the tenodesis group was significantly lower than that of the tenotomy group (55 ± 9 and 61 ± 8 years, P < .001). The other demographics were comparable. Among the patients with tenotomy, 20% (n = 63) developed a Popeye sign, compared to only 6.3% (n = 25) in the tenodesis group (age-adjusted relative risk 3, 95% confidence interval 1.9-4.8; P < .001). There were no significant differences in shoulder function. The subjective shoulder value was lower in the Popeye group (82 ± 19% vs. 86 ± 15%, P = .010).

Conclusion

Patients with tenotomy of the biceps tendon are 3 times more likely to develop a Popeye sign compared to tenodesis. Popeye sign after ARCR seems to have no relevant effect on the clinical outcome and pain even though the subjective shoulder value was lower in patients with Popeye sign.

Arthroscopic Suprapectoral Biceps Tenodesis: A Knotless, Onlay, All-Suture Anchor Technique

Anterior shoulder pain is a common complaint often caused by pathology of the long head of the biceps such as biceps tendinitis, partial biceps tears, biceps instability, and SLAP lesions. Surgical treatment of biceps pathology includes tenotomy versus tenodesis, with tenodesis being favored in young, active patients owing to less cramping pain and superior outcomes in terms of shoulder function and cosmesis. Various surgical techniques for tenodesis of the long head of the biceps exist, with varying indications. Subpectoral biceps tenodesis is primarily indicated for zone 2 to 3 tendon pathology and revision biceps tenodesis. Secondary indications include overhead athletes, chronic biceps tendinopathy, and rotator cuff repair. Proximal arthroscopic biceps tenodesis performed "high in the groove" has been shown to preserve biceps length and reduce Popeye deformity compared with tenotomy. Knotless techniques are becoming popular; they provide low-profile fixation that limits knot abrasion and is not reliant on knot security for fixation. We present a variation of suprapectoral biceps tenodesis using knotless fixation in an onlay technique.

Both Isolated Long Head of the Biceps Tenotomy and Tenodesis Are Effective for Symptomatic Rotator Cuff Repair Revision

Background: Symptomatic rotator cuff (RC) repair continues to be a complex issue. Leaving the long head of the biceps (LHB) in place might increase the risk of residual pain, even in the case of a healed RC. The purpose of this study was to assess the clinical outcomes of isolated LHB tenotomy and tenodesis as a revision procedure in symptomatic patients that had previously undergone an arthroscopic RC repair with no clinical or MRI evidence of RC retear. Methods: A retrospective analysis was conducted on patients with a persisting painful shoulder after an arthroscopic RC repair with no clinical or MRI signs of cuff retear, undergoing an isolated arthroscopic biceps tenotomy or tenodesis as a revision procedure. Functional outcomes were assessed preoperatively and at a minimum of 24 months of follow-up. Results: A total of 88 patients were included. The biceps tendon was managed with biceps tenodesis in 64 patients and tenotomy in 24 patients. VAS, Constant Score, SSV and active anterior elevation were all significantly improved after revision surgery. There was no significant difference between pre- and postoperative anterior passive elevation. No significant difference was shown between the tenodesis and tenotomy groups. Conclusions: The present study demonstrated that both isolated tenotomy and tenodesis are effective and safe in treating patients with a symptomatic shoulder after RC repair at a 2-year follow-up with a very low complication rate. Although tenodesis did not show any significant clinical benefit outcomes compared to tenotomy, it might be associated with a lower risk of Popeye deformity.

The Clinical Outcomes of Arthroscopic Tenotomy versus Tenodesis with Medium-to-Massive Rotator Cuff Tear in the Elderly: A Retrospective Study

Purpose

Shoulder arthroscopic repair of rotator cuff tears with simultaneous treatment of lesions of the long head of the biceps tendon has become increasingly accepted. However, the clinical outcomes between tenotomy and tenodesis remain unclear. This study aimed to compare the efficacy of tenotomy and tenodesis combined with rotator cuff repair in elderly patients with medium-to-massive rotator cuff tears.

Patients and Methods

We conducted a retrospective trial of patients aged > 60 years with medium-to-massive rotator cuff tears who underwent arthroscopic rotator cuff repair with tenotomy or tenodesis. This study included 96 patients: 47 in the tenotomy group and 49 in the tenodesis group. At 3 and 6 months after surgery and at the last follow-up, the American Shoulder and Elbow Surgeons (ASES) score, Constant-Murley score (CS score), anterior shoulder pain (VAS score), elbow flexion strength and supination strength, and complications were recorded.

Results

At 3 months postoperatively, ASES score, CS score and strength of elbow flexion of the tenodesis group were significantly better than those of the tenotomy group. In addition, the VAS score is 4.4 ± 1.4 and 3.3 ± 1.3 in the tenodesis and tenotomy respectively (p = 0.039). At the final follow-up, despite no significant statistical differences in ASES scores, CS scores, VAS scores, and flexion strength between the two groups, the variation in the above items in the tenodesis group was statistically lower than that in the tenotomy group. No difference was observed in the rates of complications and revision between the groups.

Conclusion

For people over 60 years of age with medium to massive rotator cuff tears, postoperative shoulder function of tenodesis is superior to tenotomy, and functional recovery is relatively more stable after tenodesis than after tenotomy.

Arthroscopic Suprapectoral Biceps Tenodesis Using an Onlay Technique

Tenodesis of the long head of biceps is a common shoulder surgical procedure. Tenodesis can be performed either arthroscopically or open and within the glenohumeral joint, within the bicipital groove, or below the pectoralis major tendon insertion. Arthroscopic tenodesis of the biceps tendon reduces the risk of infection. Our technique may also address persistent pain due to over tensioning of the tenodesis or from lesions hidden within the groove, such as bicipital synovitis or partial tendon tears, that are not visualized in a standard open technique. We describe an all-arthroscopic onlay technique for biceps tendon fixation at an extra-articular position within the bicipital groove, above the pectoralis major insertion. The technique uses standard arthroscopic equipment and a single knotless suture anchor.

Raised body mass index and reduced muscle bulk reduces the incidence of Popeye's deformity post tenotomy of long head of biceps brachii

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level-III evidence.

TYPE OF STUDY

Retrospective comparative study.

Complete Proximal Long Head Biceps Tendon Rupture in an Elite 17-year-Old Softball Pitcher: A Case Report

CASE

This case report describes the successful treatment of a year-round teenage softball pitcher who sustained a proximal biceps tendon rupture who underwent successful subpectoral tenodesis. To our knowledge, this is the only reported case of such an injury occurring in an underhand throwing teenage athlete.

CONCLUSION

This case highlights an unusual instance of a sport-related injury in an adolescent softball pitcher, suggesting that the softball pitch in elite athletes may put similar stress on the shoulder to overhead throwing athletes over time and further demonstrating that patients may continue to have success at elite levels of competition after tenodesis.

Arthroscopic suprapectoral biceps tenodesis utilizing the subacromial locking stitch anchor (SALSA) technique

Biceps tenodesis is an accepted treatment option for various pathologies of the long head of the biceps tendon and labrum. Many techniques have been published, both arthroscopic and open, that utilize various fixation techniques and locations of the tenodesis, yet none has been proven to be superior. We introduce a novel method, the SALSA (subacromial locking stitch anchor), an all-arthroscopic suprapectoral biceps tenodesis utilizing a running locking stitch from a double-loaded biocomposite anchor. This technique provides a reliable method of multipoint fixation including the transverse humeral ligament that avoids many of the potential complications encountered with other techniques.

Biceps tenotomy vs. tenodesis in patients undergoing transtendinous repair of partial thickness rotator cuff tears

Background

Patients with partial thickness rotator cuff tears (PTRCTs) often present with concurrent pathology of the long head of the biceps tendon (LHBT). To address both conditions simultaneously, long head of the biceps (LHB) tenotomy or tenodesis can be performed at the time of arthroscopic rotator cuff repair (RCR). This study aims to compare postoperative shoulder active range of motion (AROM) and complications following transtendinous RCR with concurrent LHB tenodesis or tenotomy.

Methods

A total of 90 patients with PTRCTs met inclusion criteria for this study. Patients who underwent tear-completion-and-repair, revision surgery, or open repair of the LHB tendon were excluded. Patients were stratified into tenotomy, arthroscopic suprapectoral tenodesis, or no biceps operation cohorts and were propensity matched 1:1:1 on age, sex, body mass index, and smoking status. Primary outcome measures included AROM in forward flexion, abduction, external rotation, and internal rotation at 6 weeks, 3 months, and 6 months postoperatively. The development of severe stiffness and rates of rotator cuff retear at final follow-up were recorded as secondary outcomes.

Results

When comparing the tenotomy and tenodesis cohorts, tenotomy patients were found to have increased AROM at 3 months in forward flexion (153.2° vs. 130.1°, P = .004), abduction (138.6° vs. 114.2°, P = .019), and external rotation (60.4° vs. 43.8°, P = .014), with differences in forward flexion remaining significant at 6 months (162.4° vs. 149.4°, P = .009). There were no significant differences in interval rates of recovery in any plane between cohorts. Additionally, there were no significant differences in rates of symptomatic retears between groups (P = .458). Rates of severe postoperative stiffness approached but did not achieve statistical significance between tenotomy (4.2%) and tenodesis (29.2%) cohorts (P = .066). Smoking status was a significant predictor of severe stiffness (odds ratio, 13.69; P = .010).

Conclusion

Despite significant differences in absolute AROM between cohorts, the decision to perform tenotomy or tenodesis was not found to differentially affect rates of AROM recovery for patients undergoing arthroscopic transtendinous RCR for PTRCT. Notably, however, transient stiffness complications were more commonly observed in smokers, and data trends suggested an increased risk of stiffness for patients undergoing LHB tenodesis. Overall, postoperative stiffness is likely multifactorial and attributable to both patient- and procedure-specific factors, and LHB tenotomy may be more appropriate for patients with risk factors for developing stiffness postoperatively.

Diagnostic performance of long head of biceps tendon tears on MRI: systematic review and meta-analysis

OBJECTIVES

The purpose of this meta-analysis was to determine the diagnostic performance of conventional MRI and MR arthrography for tendinosis, and partial and complete tears of the long head of the biceps tendon (LHBT) using arthroscopy as the reference standard.

MATERIALS AND METHODS

A systematic review was performed using predefined data fields in PubMed, and all articles published from January 2000 up to April 2022 were retrospectively pooled and reviewed. Six MRI studies on complete tear (n = 555) and ten studies on partial tear/tendinosis (n = 2487) were included in the analysis. Two of the included studies in each group investigated the use of MR arthrography. The data sets were analyzed using a univariate approach with the DerSimonian and Laird random effects model and the proportional hazards model.

RESULTS

MRI shows high specificities in diagnosing complete tears of the LHBT ranging from 93.0 to 99.0%. Diagnostic sensitivity was more heterogeneous ranging from 55.9 to 90.0%. The overall negative likelihood ratio was 0.29 (95% CI: 0.17-0.50) and the overall positive likelihood ratio was 37.3 (95% CI: 11.9-117.4). The mean sensitivity in diagnosing partial tear/tendinosis of the LHBT was 67.8% (95% CI: 54.3-78.9%) and the specificity was 75.9% (95% CI: 63.6-85.0%), resulting in a balanced accuracy of 71.9%. The overall negative likelihood ratio was 0.44 (95% CI: 0.32-0.59) and the overall positive likelihood ratio was 2.64 (95% CI: 1.91-3.65).

CONCLUSION

MRI is highly specific for the diagnosis of complete tears of the LHBT, whereas diagnostic sensitivity was more heterogeneous. The diagnosis of partial tears and/or tendinosis of the LHBT remains challenging on MRI, which may warrant complementary clinical examination or other imaging modalities to increase diagnostic confidence in equivocal cases.

CLINICAL RELEVANCE STATEMENT

Conventional MRI and MR arthrography have high diagnostic performance for complete tendon tear when compared to arthroscopy. The diagnosis of tendinosis/partial tears remains challenging and may require comparison with clinical tests and other imaging modalities.

KEY POINTS

•There is no clear consensus regarding the primary imaging modality for the evaluation of LHBT disorders. •Conventional MRI and MR arthrography are highly specific in diagnosing complete tears of the LHBT. •Diagnosis of partial tears/tendinosis of the LHBT on conventional MRI and MR arthrography remains a diagnostic challenge.

Arthroscopic Suprapectoral Retensioning Biceps Tenodesis

Tendinopathy of the long head of biceps is a relatively common pathology that we usually see in most of our shoulder arthroscopy procedures. Surgical treatment for long head of biceps tendinopathies ranges from simple biceps tenotomy to biceps tenodesis depending on many factors, two of which are the age and the patient's level of activity. Various techniques in the literature for biceps tenodesis have been described, such as whether to do it open or arthroscopically, suprapectoral or subpectoral, as well as the type of fixation to be used. However, the optimal option is still debatable. In this Technical Note, we describe an arthroscopic technique for distal suprapectoral biceps tenodesis using a knotless corkscrew anchor that has many advantages, such as being an all-arthroscopic with the ability to retension the tendon after implantation. We support our technique with photos and videos with detailed explanations of the technique.

Arthroscopic biceps tenodesis using press-fit bony plug: a case series study

PURPOSE

To assess the feasibility, operative time, clinical outcomes, possible complications, and failure rates of all-through arthroscopic biceps tenodesis using press-fit bony plug technique.

METHODS

This prospective case series study involved 30 skeletally mature patients with long head of biceps pathology (tendinitis after failure of conservative treatment, subluxation, dislocation, or tendon tears). All patients were followed up for 24 months at least.

RESULTS

Twenty-nine patients regained full shoulder and elbow range of motion; one case suffered from reflex sympathetic dystrophy. There was a significant improvement in the constant, ASES, and VAS scores when comparing the pre-operative and post-operative values. The average biceps strength was 96% compared to the opposite healthy side. No cases were complicated by neuro-vascular deficits or failure of the tenodesis.

CONCLUSION

Press-fit biceps tenodesis is safe and accessible with low economic demands. We recommend this technique to be used more often when addressing patients with long head of biceps pathologies.

REGISTRATION DATA

Registration number: N-1562023. Registration date: June 2022 "Retrospectively registered".

The Effect of Concomitant Biceps Tenodesis on Revision Surgery Rates After Primary Rotator Cuff Repair

INTRODUCTION

We aimed to use a national database to compare the 4-year revision surgery rates after rotator cuff repair (RCR) in patients with concomitant biceps tenodesis (BT) versus those without BT.

METHODS

A retrospective cohort analysis was conducted using the PearlDiver database from 2015 to 2017. Patients undergoing primary open and arthroscopic RCR with and without BT were identified. Demographic variables, 90-day complications, and 2- and 4-year revision surgery rates were analyzed, and a multivariable logistic regression was conducted.

RESULTS

Of the 131,155 patients undergoing RCR, 24,487 (18.7%) underwent concomitant BT and 106,668 (81.3%) did not. After controlling for comorbidities and demographics, patients with concomitant BT were associated with lower odds of all-cause revision (OR; P-value [0.77; P < 0.001]), revision BT (0.65; P < 0.001), revision RCR (0.72; P < 0.001), and shoulder arthroplasty (0.81; P = 0.001) within 4 years when compared with those without concomitant BT.

DISCUSSION

In our analysis, patients undergoing primary RCR with concomitant BT had 35% reduced odds of revision BT and 23% reduced odds of any all-cause revision within 4 years when compared with those without concomitant BT. This suggests that tenodesis at the time of primary RCR may be associated with a reduction in the utilization of ipsilateral shoulder revision surgery rates.

An All-Arthroscopic Simple Double 360° Lasso Loop Technique for Supraopectoral Biceps Tenodesis

In many shoulder joint diseases, there is often a combination of long head biceps tendon（LHBT）pathology. Biceps pathology is one of the main causes of shoulder pain, and it is effectively managed with tenodesis. Biceps tenodesis can be performed in a variety of ways with different fixation and at different locations. This article introduces an all-arthroscopic suprapectoral biceps tenodesis technique with a 2-suture anchor. Double 360° Lasso Loop is used to fix the biceps tendon, and only one puncture of the biceps tendon was required, which caused little damage to the tendon and was not easy for the suture to slip and fail.

Translation and Cultural Adaptation to Portuguese of the Long Head of Biceps Tendon Score

Objective  To translate and culturally adapt the Long Head of Biceps Tendon (LHB) score into Brazilian Portuguese. Methods  The process involved translations by professionals fluent in the target language, followed by independent back translations. Next, a committee compared the original and translated versions, pretested the final version, and concluded it. Results  We translated and adapted the questionnaire according to the proposed methodology. In the first version in Portuguese (VP1) there was divergence regarding the translation of twelve terms. Compared to the original version, the back translation of VP1 presented eight diverging terms. A committee prepared a second version in Portuguese (VP2) and applied it to a pretest group consisting of 30 participants. Finally, we conceived the third version in Portuguese, called LHB-pt. Conclusion  The translation and cultural adaptation into Brazilian Portuguese of the LBH score was successfully accomplished.

Does the timing of tenotomy during biceps tenodesis affect the incidence of Popeye deformity and clinical outcome? An analysis of short-term follow-up of 2 techniques

BACKGROUND

There are multiple techniques that attempt to maintain anatomic length-tension relationship during biceps tenodesis. However, no direct comparison has been performed with respect to the timing of biceps tenotomy during biceps tenodesis. This study aims to assess the incidence of Popeye deformity and clinical outcomes of 2 all-arthroscopic techniques for biceps tenodesis based on timing of the biceps tenotomy.

METHODS

A consecutive series of patients undergoing arthroscopic biceps tenodesis with concomitant rotator cuff tears were enrolled from 2019 to 2021. Biceps tenodesis performed after tenotomy formed the first cohort (group 1). The other cohort had biceps tenodesis performed prior to biceps tenotomy (group 2). Postoperative anterior arm pain, biceps muscle spasms, and patient perceptions of the appearance of the bicep muscle were assessed. In addition, patient-reported outcomes (PROs) were collected at 3 months and minimum 6 months postoperatively.

RESULTS

A total of 71 patients were eligible for participation and 62 patients (53% female, age 58.7 ± 9.0 years) were enrolled (n = 33 in group 1, and n = 29 in group 2). There were no differences between groups with respect to gender, age, and laterality of biceps tenodesis, as well as type and size of rotator cuff repair. At 3-month follow-up, Veterans RAND 12-Item Health Survey (VR-12) physical health summary scores were significantly improved in group 2 (44.8 ± 9.7) compared with group 1 (34.1 ± 3.4) (P = .03). In addition, patients in group 2 experienced significantly less pain in their anterior arm than patients in group 1 (19% vs. 33%, P = .02). There were no differences in biceps muscle spasm (3.4% vs. 5.2%, P = .21) and no other differences in PROs between groups. Final follow-up averaged 11.6 ± 3.3 months in group 1 and 11.8 ± 5.5 months in group 2. There were no significant differences in patient-perceived biceps Popeye deformity between group 1 (12.1%) and group 2 (0%) (P = .652). Furthermore, there were no differences in American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, EuroQol-5 Dimension, Patient-Reported Outcomes Measurement Information System Global Health (PROMIS 10) physical health, PROMIS 10 depression, VR-12 physical health summary, and Single Assessment Numeric Evaluation scores between the 2 technique groups.

CONCLUSION

Patients with tenotomy performed after tenodesis had better VR-12 physical health summary scores and less arm pain than patients with tenotomy performed before tenodesis at 3-month follow-up. However, there were no differences in any outcome at final follow-up of nearly 1-year. In addition, there were no differences in perceived Popeye deformity between groups at any time period.

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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

Background

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

Methods

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

Results

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

Conclusion

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

Two-Year Clinical Outcomes and Survivorship After Isolated Biceps Tenodesis

PURPOSE

The purpose of this study was to evaluate clinical outcomes and survivorship of isolated biceps tenodesis (BT) at a minimum of 2 years and to identify patient-specific factors associated with these outcomes in patients undergoing BT without concomitant rotator cuff repair (RCR). We hypothesized that patient-reported outcomes would be significantly improved on American Shoulder and Elbow Surgeons Survey (ASES) and Single Assessment Numeric Evaluation (SANE), with a high rate of survivorship (>90%) at 2-year follow-up.

METHODS

A retrospective review of an institutional registry was performed to identify patients who underwent BT from July 2016 to December 2017. Patients >18 years old who underwent an open or arthroscopic BT procedure using an interference screw, button, or anchor for underlying bicipital pathology, without a concomitant RCR or shoulder arthroplasty, and were a minimum of 2 years postoperative were included. Patients were administered ASES and SANE questionnaires preoperatively and at final follow-up. Survivorship was evaluated using Kaplan-Meier analysis. Failure was defined as any patient who underwent reoperation related to the index surgery.

RESULTS

A total of 110 patients (mean ± standard deviation age, 48.60 ± 12.14 years) who underwent isolated BT with a follow-up of 24.90 ± 3.95 months were included in analysis. There was a significant improvement in ASES and SANE at final follow-up (P < .001), with 81% to 84% of patients achieving minimal clinically important difference (MCID), 72% to 82% achieving substantial clinical benefit (SCB), and 72% to 80% achieving patient-acceptable symptom state (PASS). Worker's Compensation (WC) patients had a decreased likelihood of achieving PASS on ASES (P = .015) and SANE (P = .012). Four cases were deemed failures (3 revision BTs and 1 capsular debridement) at 15.09 ± 9.57 months. WC did not have a significant effect on likelihood of BT failure.

CONCLUSION

Biceps tenodesis provided significant clinical improvement and high rates of survivorship 2 years postoperatively. WC was associated with a decreased likelihood of achieving PASS. These results support the continued use of isolated BT for treating biceps pathology.

LEVEL OF EVIDENCE

IV, case series.

No Difference in Clinical Outcomes for Arthroscopic Suprapectoral Versus Open Subpectoral Biceps Tenodesis at Midterm Follow-up: A Randomized Prospective Analysis

BACKGROUND

We have previously reported the 1-year outcomes of arthroscopic suprapectoral biceps tenodesis (ASPBT) versus open subpectoral biceps tenodesis (OSPBT) for the management of long head of the biceps tendon (LHBT) pathology. While patients had similar 1-year biceps muscle strength and pain, longer-term functional outcomes are unknown.

PURPOSE

To directly compare clinical outcomes of ASPBT versus OSPBT with interference screw fixation, distal to the bony bicipital groove, at a minimum of 2 years' follow-up.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A total of 85 patients undergoing biceps tenodesis (BT) for LHBT disease were randomized into the ASPBT or OSPBT group. Both techniques utilized polyether ether ketone inference screws for tenodesis fixation. Patients completed American Shoulder and Elbow Surgeons (ASES), Constant subjective, and Single Assessment Numeric Evaluation (SANE) questionnaires preoperatively and again at 6 months, 12 months, and at the final follow-up at a minimum of 24 months.

RESULTS

A total of 73 patients (37/42 randomized to ASPBT [88%]; 36/42 randomized to OSPBT [86%]) with a mean age of 50.4 ± 10.3 years and a mean body mass index of 29 ± 7.9 were included in clinical outcome analyses. The mean final follow-up was 2.9 years (ASPBT, 3 years; OSPBT, 2.8 years [range 2-5.2 years]). Comparison of demographic characteristics and intraoperative findings showed no significant differences in age, sex, concomitant procedures, and rotator cuff disease. No statistically significant differences in the ASES (P = .25), Constant subjective (P = .52), and SANE scores (P = .61) were found at the final follow-up. Clinical outcomes scores showed no significant improvement from a mean of 12.6 months to the final follow-up at 34.5 months (ASPBT: ASES, P = .43; Constant, P = .25; SANE, P = .45 vs OSPBT: ASES, P = .65; Constant, P = .78; SANE, P = .70). No patients required revision of BT in either group.

CONCLUSION

This study reported a minimum of 2-year follow-up of patients undergoing ASPBT or OSPBT, utilizing the same interference screw technique, for the management of LHBT pathology in the setting of concomitant shoulder procedures. There were no significant differences in patient-reported outcomes and complication rates found at any time point.

REGISTRATION

NCT02192073 (ClinicalTrials.gov identifier).

Diagnostic accuracy of magnetic resonance imaging for partial tears of the long head of the biceps tendon in patients with rotator cuff tears

Background

Magnetic resonance imaging (MRI) is useful for diagnosing shoulder diseases preoperatively. However, detection of partial tears of the long head of the biceps tendon (LHBT) using current clinical tests and imaging modalities is difficult. We aimed to evaluate the accuracy of radial-slice MRI for diagnosing partial tears of the LHBT. We hypothesized that radial-slice MRI may be a valuable diagnostic tool for assessing diagnosing tears of the LHBT.

Methods

We retrospectively investigated 118 patients who underwent shoulder arthroscopy for rotator cuff tears. Intraoperative LHBT findings were compared with the identification of partial tears of the LHBT on conventional-slice MRI and radial-slice MRI, using a 3.0-T system. We calculated sensitivity, specificity, accuracy, and positive and negative predictive values for the detection of LHBT tears. Inter- and intraobserver reliability for radial-slice MRI was calculated using kappa statistics.

Results

We diagnosed 69 patients (58%) without any LHBT tears and 49 with partial tears (42%), arthroscopically. Sensitivity, specificity, accuracy, and positive and negative predictive values of conventional-slice MRI for detection of partial tears of the LHBT were 52%, 94%, 78%, 92%, and 58%, respectively. Radial-slice MRI had 84% sensitivity, 90% specificity, 86% accuracy, and 92% positive and 80% negative predictive values for partial tears of the LHBT. Inter- and intraobserver reliability for radial-slice MRI was 0.69 and 0.74, respectively, corresponding to high reproducibility and defined as good.

Conclusion

Radial-slice MRI demonstrated significantly higher sensitivity than conventional-slice MRI. These results indicate that radial-slice MRI is useful for diagnosing LHBT partial tears.

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

INTRODUCTION

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

HYPOTHESIS

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

MATERIALS AND METHODS

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

RESULTS

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

DISCUSSION

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

CONCLUSION

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

LEVEL OF EVIDENCE

III; case-control.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level IV.

The "Not" Good, the Bad and the Ugly: Prevention and Management of Common Intraoperative and Delayed Complications in Orthopedic Sports Medicine Surgical Procedures

Despite advances in techniques designed to make arthroscopic sports medicine procedures simple, complications still arise in the operating room; even in the most trained hands. However, what marks a skilled surgeon is not just the ability to steer the ship amidst smooth seas, but a knack for getting out of trouble once things deviate from the set course. Each surgical case presents a unique challenge, and no 2 are the same. For this reason, a true expert surgeon must know how to deal with "complications" ranging from a mild swell to a raging storm. In this review we present strategies to prevent and navigate some of the most common, and fearsome complications a sports medicine surgeon may face during surgery. A great surgeon is one that acknowledges that throughout their career it is not a question of "if" these situations will arise, but "when"; and preparation is the key to success.

Clinical outcome comparison of suprapectoral and subpectoral tenodesis of the long head of the biceps with concomitant rotator cuff repair: A systematic review

BACKGROUND

Simultaneous repairs of rotator cuff and biceps tenodesis can be managed by tenodesis of long head of biceps tendon to a subpectoral or suprapectoral area. This review investigated long head of biceps tendon tenodesis with concomitant rotator cuff repair and evaluated the clinical outcomes and incidences of complications based on tenodesis location.

METHODS

Medline, Cochrane, and Embase databases were searched for published, randomized or nonrandomized controlled studies and prospective or retrospective case series with the phrases "suprapectoral," "subpectoral," "tenodesis," and "long head of biceps tendon". Those with a clinical evidence Level IV or higher were included. Non-English manuscripts, review articles, commentaries, letters, case reports, and sole long head of biceps tendon tenodesis articles were excluded.

RESULTS

From 481 studies, 13 were chosen. In total, 1194 subpectoral and 2520 suprapectoral tenodesis cases were investigated. Postoperative Constant-Murley and American Shoulder and Elbow Surgeons mean scores showed similar good results. In terms of complication incidences, while transient nerve injuries were more commonly seen in patients with subpectoral tenodesis, persistent bicipital pain and Popeye deformity are mostly seen in patients with suprapectoral tenodesis.

DISCUSSION

Biceps tenodesis to suprapectoral or subpectoral area with concomitant rotator cuff repair demonstrated similar outcomes. Popeye deformity and persistent bicipital pain were higher in suprapectoral area and transient neuropraxia was found to be higher in subpectoral area.Level of evidence: IV.

Clinical Outcomes of Revision Biceps Tenodesis for Failed Long Head of Biceps Surgery: A Systematic Review

PURPOSE

We summarize the indications, assess the modes of failure, and analyze the clinical and functional outcomes of revision biceps tenodesis after failed primary surgical treatment of long head of biceps (LHB) pathology.

METHODS

A computerized search of PubMed, EMBASE, and CINAHL databases and manual screening of selected article reference lists was performed in September 2020. Randomized controlled trial, cohort, case-control, and case series studies reporting clinical outcomes of revision biceps tenodesis following failed LHB surgery were eligible. Patient demographics, indications for revision, intraoperative findings, surgical techniques, and patient-reported outcomes were recorded. Functional assessment and pain scores were assessed and summarized as forest plots with means and 95% confidence intervals.

RESULTS

Five of 465 identified studies met inclusion criteria, encompassing 70 revision biceps tenodesis procedures with mean follow-up of 2.4-6.4 years. The failed index procedure was biceps tenodesis in 62 patients and tenotomy in 8 patients. The most common indications for revision were pain or cramping and rerupture, cited by 4 and 3 articles, respectively. After failed conservative treatment, open subpectoral revision tenodesis was performed with concomitant arthroscopic debridement in 65 of 70 cases. Common intraoperative findings at time of revision were adhesions or scarring (39.0-83.0%), fixation failure (8.7-75.0%), and biceps rupture (17.4-80.0%). Revision tenodesis patients reported good to excellent functional outcomes with improvements in Single Assessment Numeric Evaluation, American Shoulder and Elbow Surgeons Shoulder, and visual analog scale pain scores, and satisfaction ranged from 88.0 to 100%. All studies demonstrated moderate quality of evidence and risk of bias when critically appraised.

CONCLUSION

This systematic review of 5 moderate risk of bias studies demonstrated that the most common reasons for revision biceps tenodesis were pain or cramping and rerupture. Open subpectoral revision tenodesis with concomitant arthroscopic debridement provided improvements in functional scores with high patient satisfaction at mid-term follow up.

LEVEL OF EVIDENCE

IV, Systematic Review of level III and IV investigations.

Impact of shoulder, elbow and forearm position on biceps tendon excursion: A cadaveric study

PURPOSE

This experimental study investigated the long head biceps tendon (LHBT) excursion that occurs at various positions of the upper limb during tendon stabilizing procedures. We hypothesized that shoulder abduction, elbow extension and forearm pronation would maximize the excursion of the LHBT and potential impacts on tendon stabilization.

MATERIALS & METHODS

Forequarter specimens from 12 fresh frozen cadavers were used in this study. The study was performed at 0° and 30° of shoulder abduction. Elbow position was either 90° of flexion or full extension with the forearm either in full pronation or supination. A total of 14 combinations of positions were studied. A load of 55 N was applied to the distal biceps. The excursion of the proximal part of LHBT was measured for each of the different positions.

RESULTS

At a shoulder position of 30° of flexion, shoulder abduction of 30° created significantly greater excursion than 0° of shoulder abduction (p < 0.001). Both full extension of the elbow and full pronation of the forearm also showed significant excursion of the tendon when compared to supination (p < 0.001).

CONCLUSIONS

The position of the shoulder, elbow and forearm has a significant effect on biceps excursion. Thirty degrees of shoulder abduction and 30° of forward flexion with the elbow in full extension and the forearm in full pronation maximizes excursion.

CLINICAL RELEVANCE

Information about the excursion of the LHBT affected by the position of the upper limb is useful for any biceps tendon stabilizing procedure. During an operation, the position of the upper limb should be monitored in order to maintain a proper anatomic length-tension relationship.

Long head of biceps tenotomy versus tenodesis: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To compare tenotomy versus tenodesis for the treatment of long head of the biceps tendon pathologies. The primary outcome was the shoulder functional outcome. The secondary outcomes consisted of postoperative pain, elbow flexion and forearm supination strengths and postoperative complications.

METHODS

PubMed, MEDLINE, Google Scholar and Web of Science were searched until April 2020. Included studies were randomized controlled trials with a minimum 12 months' follow-up.

RESULTS

Both treatments had similar improvement on the Constant-Murley score at 6 months and 12 months. However, tenotomy had a significantly lower Constant-Murley score at two years with a mean difference of -1.13 (95% confidence interval -1.9, -0.35). Furthermore, tenotomy had a risk ratio of 2.46 (95% confidence interval 1.66, 3.64) for developing Popeye's deformity. No significant difference was detected in other functional outcomes, pain, or elbow flexion and forearm strength indices.

DISCUSSION

Tenodesis and tenotomy are both well-established techniques that similarly yield satisfactory outcomes. Despite that tenodesis had a statistically significant better Constant-Murley score at two years, this was clinically irrelevant. With the current evidence, we recommend either technique for the management of the long head of the biceps tendon pathologies.

LEVEL OF EVIDENCE

Therapeutic, Level II.

Evaluation of Biceps Tenotomy or Tenodesis on Fatty Infiltration of the Biceps Muscle

Objective  The objective of the present study was to determine whether there is fatty infiltration (FI) of the biceps brachii muscle mass after tenotomy or tenodesis for the treatment of tendon injuries in the long head of the biceps and to establish a relationship between FI with changes in the length of muscle fibers.

Methods  Clinical and imaging analysis of 2 groups of patients (biceps tenodesis [16 patients] and biceps tenotomy [15 patients]). In both groups, we compared the findings on the contralateral side of each patient (control group). All patients had undergone unilateral biceps tenodesis or tenotomy, with postoperative follow-up of > 1 year. Magnetic resonance imaging (MRI) was performed on both arms of each patient following a specific protocol. Strength of elbow flexion was measured with a manual dynamometer, and the results were subjected to statistical analysis.

Results  The mean postoperative period before the MRI was 5 years, and no case of FI was observed in the anterior compartment of either arm of the evaluated patients. Seven patients had moderate or severe deformity in the operated arm. We found no significant relationship between arm deformity ( p  = 0.077), flexion strength percentage ( p  = 0.07) or pain on palpation of the bicipital groove ( p  = 0.103).

Conclusion  None of the evaluated patients had evidence of FI in the muscle mass of the anterior arm compartment after the procedures. It was not possible to establish a correlation between the discrepancy of the biceps muscle length measured by MRI and the presence of FI in the anterior compartment of the arm.

Short-Term Clinical and Return-to-Work Outcomes After Arthroscopic Suprapectoral Onlay Biceps Tenodesis With a Single Suture Anchor

Purpose

To describe short-term outcomes of arthroscopic suprapectoral onlay biceps tenodesis using a single all-suture anchor with respect to validated outcome measures, return to work, objective strength and motion data, and biceps-specific testing.

Methods

This study describes a consecutive series of patients undergoing arthroscopic suprapectoral onlay biceps tenodesis performed by a single surgeon from January to December 2017. Patients were evaluated preoperatively and postoperatively with the American Shoulder and Elbow Surgeons questionnaire, visual analog scale, Single Assessment Numeric Evaluation, Veterans RAND 12-Item Health Survey, and 12-Item Short Form survey, and return-to-work survey. Postoperative strength, range of motion, and biceps-specific testing was also performed.

Results

This study included 50 patients (26 men and 24 women), with an average age (± standard deviation) of 50.1 ± 10.9 years and average final follow-up of 21.3 ± 8.5 months. Among employed patients, 32 (71.1%) returned to work at an average of 4.6 ± 2.3 months. Light-duty workers returned to work at a significantly greater rate (85.7% vs 33.3%, P = .016) and in less time (2.6 ± 2.0 months vs 6.8 ± 4.2 months) than heavy-duty workers. No differences were found between operative and nonoperative sides in the biceps apex distance (P = .636) or range of motion in elbow flexion and extension (P > .9 for both), supination (P = .192), or pronation (P = .343) postoperatively. Strength in elbow flexion (P = .002), as well as shoulder forward elevation (P < .001) and external rotation (P < .001), increased postoperatively. Significant patient-reported improvements were noted in the American Shoulder and Elbow Surgeons score, visual analog scale pain score, Single Assessment Numeric Evaluation score, Constant-Murley score, and Veterans RAND 12-Item Health Survey and 12-Item Short Form physical component scores (P ≤ .001 for all). A postoperative Popeye deformity developed in 5 patients (10%).

Conclusions

Arthroscopic suprapectoral onlay biceps tenodesis with a single all-suture anchor can provide overall excellent clinical outcomes regarding strength, motion, and validated patient-reported outcome questionnaires. Return to occupational activities may be less predictable and more prolonged for heavy laborers. A small number of patients may experience cosmetic deformity postoperatively.

Level of Evidence

Level IV, therapeutic case series.

Modified Superior Capsule Reconstruction Using the Long Head of the Biceps Tendon as Reinforcement to Rotator Cuff Repair Lowers Retear Rate in Large to Massive Reparable Rotator Cuff Tears

PURPOSE

To retrospectively assess the clinical outcomes of the patients with large to massive reparable RCTs treated by arthroscopic rotator cuff repair (ARCR) combined with modified superior capsule reconstruction (mSCR) using the long head of biceps tendon (LHBT) as reinforcement with a minimum of 2 years of follow-up.

METHODS

We retrospectively evaluated 40 patients with large to massive reparable RCTs who underwent ARCR and mSCR (group I) between February 2017 and June 2018 (18 patients) or underwent ARCR and tenotomy of LHBT performed at the insertion site (group II) between January 2015 and January 2017 (22 patients). The pain visual analog score (VAS) was assessed preoperatively and 1, 3, 6, 12, 24 months postoperatively. American Shoulder and Elbow Surgeons (ASES) scores, the University of California, Los Angeles (UCLA) shoulder rating scale, and active range of motion (AROM) were assessed before surgery and 6, 12, and 24 months after surgery. The integrity of the rotator cuff and mSCR was evaluated using magnetic resonance images at 12 months postoperatively.

RESULTS

After surgery, both groups had significantly improved in VAS, ASES, UCLA and AROM scores in the final follow-up. There were no significant between-group differences in the characteristics of the patients before surgery. Group I had improved pain relief at 1 month (P < .001) and at 3 months (P < .01) after surgery. For the AROM, group I (flexion, external rotation, internal rotation) demonstrated better improvement than group II 6 months after surgery (all P < .05) and better internal rotation 12 and 24 months after surgery (all P < .05). The mSCR survival rate was 94.4% (17/18). The retear rate of repaired rotator cuffs for groups I and II was 16.7% (3/18) and 40.9% (9/22), respectively, and the differences were significant (P < .046).

CONCLUSIONS

ARCR combined with mSCR using LHBT as reinforcement may lead to a lower retear rate and earlier functional recovery than conventional ARCR with tenotomy of LHBT for large to massive reparable RCTs.

LEVEL OF EVIDENCE

Level III, retrospective therapeutic comparative trial.

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.

Long Head of Biceps Tenotomy Is Not Inferior to Suprapectoral Tenodesis in Arthroscopic Repair of Nontraumatic Rotator Cuff Tears: A Multicenter, Non-inferiority, Randomized, Controlled Clinical Trial

PURPOSE

To determine if long head of the biceps (LHB) tenotomy is not inferior to suprapectoral LHB tenodesis when performed in conjunction with arthroscopic repair of small- to medium-sized nontraumatic rotator cuff tears.

METHODS

This multicenter, randomized, non-inferiority trial recruited 100 participants older than 50 years who had a supraspinatus and/or infraspinatus tear sagittally smaller than 3 cm and arthroscopically confirmed LHB pathology. During arthroscopic rotator cuff repair, we randomized 48 patients to undergo suprapectoral LHB tenodesis and 52 patients to undergo LHB tenotomy. Data were collected preoperatively and at 6 weeks, 3 months, and 1 year postoperatively. The primary outcome was non-inferiority of the Constant-Murley score (CMS) at 1-year follow-up. Secondary outcomes included the Dutch Oxford Shoulder Score; Disabilities of the Arm, Shoulder and Hand questionnaire; Popeye deformity; elbow flexion strength index; arm cramping pain; and quality of life (EQ-5D score). The integrity of the rotator cuff repair was assessed with magnetic resonance imaging. Differences between intervention groups were analyzed by mixed modeling.

RESULTS

The mean CMS in the LHB tenotomy group improved from 44 (95% confidence interval [CI], 39-48) to 73 (95% CI, 68-79). In patients with LHB tenodesis, the mean CMS improved from 42 (95% CI, 37-48) to 78 (95% CI, 74-82). The difference between groups at 1-year follow-up was 4.8 (97.5% CI, -∞ to 11.4), with a P value for non-inferiority of .06. The secondary outcomes also improved over time, with no remarkable differences between groups. A Popeye deformity occurred in 33% of tenodesis patients and 47% of tenotomy patients (P = .17). Tenotomy was performed with a shorter operative time (73 minutes vs 82 minutes, P = .03). Magnetic resonance imaging showed a recurrent rotator cuff tear in 20% of all cases.

CONCLUSIONS

Although statistically "inconclusive" regarding non-inferiority of the CMS at 1-year follow-up, any observed differences between patients with LHB tenotomy and those with LHB tenodesis in all outcome scores were small.

LEVEL OF EVIDENCE

Level I, randomized controlled trial and treatment study.

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.

Arthroscopic tenotomy for treatment of biceps tendon luxation in two apprehension police dogs

CASE DESCRIPTION

A 7.5-year-old 37.8-kg (83.2-lb) sexually intact male German Shepherd Dog (dog 1) and a 2.6-year-old 28.2-kg (62.0-lb) sexually intact male Dutch Shepherd (dog 2), both apprehension police dogs, were admitted for evaluation of left and right thoracic limb lameness, respectively.

CLINICAL FINDINGS

In both dogs, signs of pain were elicited on palpation of the shoulder joint in the affected limb, and a distinct popping of the biceps brachii tendon (BT) was palpable on the craniomedial aspect of the affected joint on flexion and extension and was associated with moderate signs of pain. Biceps brachii tendon luxation (BTL) was diagnosed with dynamic musculoskeletal ultrasonography (both dogs) and MRI (dog 1).

TREATMENT AND OUTCOME

Arthroscopic BT release by tenotomy was performed in both dogs. Lameness appeared to have resolved by 8 weeks after surgery and had not recurred by the last follow-up communications at 36 and 9 months after surgery for dogs 1 and 2, respectively. Both dogs successfully returned to their level of work performed before their injury.

CLINICAL RELEVANCE

Our findings for the dogs of the present report suggested that arthroscopic BT release could be considered a viable treatment option for BTL in dogs, including police dogs or other high-performance athletic dogs. Although our findings provided encouraging results, further research, best conducted with a multicenter prospective randomized study, would be needed to establish the most reliable treatment of BTL in high-performance athletic or working dogs.

Consider Long Head of Biceps Tendon for Reconstruction of Massive, Irreparable Rotator Cuff Tear

Despite the different treatment options for irreparable and massive rotator cuff tears (RCTs), there is no optimal treatment. Thirty percent of total RCTs can be classified as irreparable because of the massive tear size and severe muscle atrophy. The reported treatment failure rate is approximately 40% for massive RCTs. RCTs may be treated conservatively or surgically depending on pain, disability, and functional demands. The surgical treatment options are many, but decision making is a challenge; the real challenge is to apply the correct procedure for the correct indication in each patient. The long head of the biceps tendon (LHBT) was used for augmentation to bridge the gap in immobile, massive RCTs. An arthroscopic biceps-incorporating technique was used for repair of large and massive RCTs, avoiding undue tension on the rotator cuff (RC). Recently, the LHBT was used for superior capsular reconstruction. This article describes the use of the LHBT for reconstruction of massive and irreparable RCTs through the following steps: (1) open exposure of the RCT, (2) debridement and subacromial decompression, (3) biceps tenotomy at the LHBT's origin on the glenoid, (4) LHBT and RC cuff mobilization, (5) passage of the LHBT through the mobilized RC and reflection onto itself, (6) tuberoplasty, and (7) fixation of the RC complex at the RC footprint.

The Loop Tenodesis Procedure-From Biomechanics to First Clinical Results

(1) Introduction: Several surgical therapy options for the treatment of pathologies of the long biceps tendon (LHB) have been established. However, tenotomy, as well as established tenodesis techniques, has disadvantages, such as cosmetic deformities, functional impairments and residual shoulder pain. This study presents the first clinical and structural results of the recently introduced loop tenodesis procedure for the LHB, developed to overcome these issues. (2) Methods: 37 patients (11 women, 26 men, mean age 52 years), who underwent loop tenodesis of the LHB were examined six months after surgery. For the clinical evaluation the Constant score, as well as the LHB score, were used, complemented by elbow flexion and supination strength measurements. The integrity of the tenodesis construct was evaluated indirectly by sonographic detection of the LHB in the bicipital groove. (3) Results: Both, the overall Constant score as well as the LHB score showed significant improvements six months postoperatively, as compared to the preoperative value. Fourteen patients (38%) presented an examiner-dependent upper arm deformity, although only five patients (13%) reported subjective cosmetic deformities. Both, flexion and supination strength were preserved compared to the preoperative level. In 35 patients (95%), the tenodesis in the bicipital groove was proofed sonographically. (4) Conclusion: The loop tenodesis of the LHB provides good-to-excellent overall clinical results after a short-term follow-up of six month. The incidence of cosmetic deformities was inferior compared to conventional therapy options (tenotomy and anchor tenodesis).

The "Sandwich Tenodesis": An Arthroscopic Technic for Combined Soft-Tissue and Bony Fixation of the Long Head of the Biceps

Pathology of the long head of the biceps can contribute to substantial shoulder pain. After nonoperative treatment has failed, either open or arthroscopic tenotomy or tenodesis can be recommended depending on age, occupation, function, and cosmetic preference. While classic tenodesis techniques rely on tendon-to-bone fixation, multiple studies have shown superior healing results for fixation between similar types of tissue, such as tendon-to-tendon. In this technique, we present the "sandwich technique," performed entirely arthroscopically. A single 4-strand anchor with bioabsorbable screw is used to provide 2 types of fixation. Two strands are first used to lasso-loop the long head of the biceps to the bicipital groove, providing bone-to-tendon fixation. The other strands are then used to anchor rotator interval tissue to the tendon, providing a similar tissue or tendon-to-tendon patch augmentation.

Humerus Fractures After Open Subpectoral Biceps Tenodesis: Three Cases with 2-year Functional Outcome Data and Review of the Literature

CASE

The authors present 3 cases of humerus fracture after biceps tenodesis performed by 3 different surgeons with radiographs and outcome scores with a minimum of 30 months follow-up. Fractures occurred between 7 days and 4 months postoperatively and include 2 fractures where tenodesis had been performed with interference screw fixation and one fracture where tenodesis had been performed with a bicortical endobutton technique.

CONCLUSIONS

These case reports highlight the risk of this complication in biceps tenodesis with bony fixation. The authors review the previously reported cases and relevant biomechanical studies that elucidate risk factors for humerus fracture and discuss alternative means to treat biceps tendon pathology.

[Injuries of the biceps-labrum complex : Principles, pathologies and treatment concepts]

BACKGROUND

The biceps-labrum complex is prone to acute lesions and degenerative changes due to its anatomical structure and the high load it has to endure. Pathological changes of these structures are common pain generators and can significantly impair shoulder function. Anatomically, the biceps-labrum complex can be divided into three zones: inside, junction and bicipital tunnel.

DIAGNOSTIC PROCEDURE

Despite the focused physical examination and advancements in imaging techniques, the exact localization of pathologies remains challenging. Arthroscopy can be used to accurately diagnose inside and junctional pathologies but extra-articular changes in the region of the bicipital tunnel can only be partially visualized.

TREATMENT

In cases of unsuccessful conservative treatment and correct indications, a high level of patient satisfaction can be surgically achieved. In young patients an anatomical reconstruction of inside lesions or tenodesis of the long head of the biceps tendon is performed; however, even tenotomy is a valuable option and can achieve equally satisfactory results. Unaddressed pathological changes of the bicipital tunnel can lead to persistence of pain. In clinical procedures performing tenodesis, both the different techniques and the implants used have been found to show similar results. This article describes the anatomical principles, pathological changes, the focused clinical instrumental diagnostics and discusses the different treatment philosophies as well as the outcome according to the recent literature.

Effectiveness and safety of tenosynovitis of the long head of the biceps brachii with acupuncture: a protocol for a systematic review and meta-analysis

Background

Tenosynovitis of the long head of the biceps (LHB) brachii is a common disease in patients over 40 years old. It can always result in chronic anterior shoulder pain and limited function. Acupuncture is one of most popular conservative treatment methods, and increasing studies indicate that it has remarkable therapeutic effects on the tenosynovitis of LHB brachii. However, the effectiveness and safety of acupuncture for treating tenosynovitis of LHB brachii remain largely uncertain. In our study, we will perform the first systematic review and meta-analysis to explore the effectiveness and safety of acupuncture on the tenosynovitis of LHB brachii.

Methods

We will search the randomized controlled trial (RCT) literatures involving acupuncture for treating tenosynovitis of LHB brachii in eight electric databases, including PubMed, Web of Science, EMBASE, the Cochrane Library, Chinese National Knowledge Infrastructure (CNKI), Chinese Biomedical Literature Database (CBM), Wanfang Database, and Technology Periodical Database (VIP). We will define the visual analog scale (VAS), the Melle score of shoulder joint functional activity, and the ability assessment of daily living activities (ADL) as the primary outcomes. Besides quality of life, adverse events caused by acupuncture will be regarded as the secondary outcomes. Quality assessment of the included studies will be independently performed according to the Cochrane Risk of Bias tool. Meanwhile, the level of evidence for results will be assessed by using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method. All analyses will be conducted by using the RevMan software V5.3.

Results

From the study, we will ascertain the effectiveness and safety of acupuncture treatment on tenosynovitis of LHB brachii.

Conclusion

The conclusion of this study will confirm the effectiveness and safety of acupuncture in the treatment of tenosynovitis of LHB brachii, which can provide new evidence to guide appropriate interventions on tenosynovitis of LHB brachii with acupuncture in the future.

Ethics and dissemination

Ethical approval is not required because no individual patient data are collected. This review will be published in a peer-reviewed journal and presented at an international academic conference for dissemination.

Trial registration

PROSPERO registration number CRD42020167434. Registered on April 28, 2020.

Physiologic Long Head Biceps Tendon Excursion Throughout Shoulder Range of Motion: A Cadaveric Study

Background:

Restoration of the long head of the biceps tendon (LHBT) length-tension relationship is critical in preserving muscle strength and efficiency when performing biceps tenodesis. While static anatomic landmarks such as the inferior border of the pectoralis major may be used intraoperatively to achieve this, shoulder position may affect the excursion of the biceps tendon and represents another variable to consider.

Purpose/Hypothesis:

The purpose of this study was to quantitatively evaluate the normal excursion of LHBT that occurs through a glenohumeral range of motion. We also sought to determine whether elbow position affects LHBT excursion. We hypothesized that LHBT excursion will be affected by glenohumeral flexion and extension, and elbow extension will result in increased excursion at each glenohumeral position compared with a neutral position.

Study Design:

Controlled laboratory study.

Methods:

A total of 10 fresh-frozen specimens underwent a standard approach for subpectoral biceps tenodesis. The LHBT was identified and tagged with a radiopaque marker within zone 3 of the bicipital tunnel. A total of 3 K-wires were then drilled into the osseous floor: one at the level of the marker in the LHBT, one at 1 cm proximal, and a third 1 cm distal. All 3 K-wires were then cut flush with the anterior humeral cortex. The specimens were next placed into 8 different positions, and the excursion of the LHBT was measured by referencing the K-wires using static fluoroscopic imaging. The results were analyzed using 1-way analysis of variance testing followed by Tukey honestly significant difference testing for pairwise comparison between each individual position and the reference position.

Results:

The average total LHBT excursion was 24.4 ± 5.2 mm between the neutral shoulder position and the other shoulder positions tested. The position of the LHBT was significantly different in the reference position compared with each of the other 7 shoulder positions (P < .001). Additionally, the 2 positions of shoulder extension had different LHBT excursions when compared with each position of shoulder flexion (P < .0001). For each shoulder position tested, the position of the LHBT was not significantly different in elbow flexion compared with extension.

Conclusion:

There is approximately 24 mm of LHBT excursion throughout the glenohumeral range of motion, with significantly different amounts of excursion in glenohumeral flexion and extension. Elbow position does not significantly affect LHBT excursion. Positioning the shoulder in extension during biceps tenodesis may overtension the biceps, while positioning the shoulder in flexion may undertension the biceps relative to the neutral position. Further research is needed to identify the optimal shoulder position for biceps tenodesis.

Clinical Relevance:

Shoulder positioning is an important consideration in establishing a normal length-tension relationship during biceps tenodesis. When compared with flexed shoulder positions, LHBT excursion significantly differs in positions of extension and in a neutral position.

The Loop 'n' Tack Knot: Biomechanical Analysis of a Novel Suture Technique for Proximal Biceps Tenodesis

Background

Secure tendon grasping is critical to the success of any tenodesis procedure. Several techniques currently used for tendon grasping can result in longitudinal splitting of the tendon, causing construct failure and failure of the tenodesis.

Purpose

To compare the Loop 'n' Tack knot as a tendon-grasping technique with other common suture techniques. We investigated the biomechanical strength and mode of failure.

Study Design

Controlled laboratory study.

Methods

Eleven matched pairs of proximal biceps were harvested from fresh-frozen cadaveric shoulders. One tendon from each pair was stitched using 1 of 4 different techniques. The suture techniques evaluated included the Loop 'n' Tack with 2 different types of high-strength nonabsorbable suture, a double half-racking stitch, and a Krakow stitch. Samples were cyclically loaded between 5 and 20 N for 100 cycles, followed by a pull to failure at 33 mm/s.

Results

The Loop 'n' Tack techniques were equivalent to the double half-racking and Krakow techniques for load to ultimate failure (P = .817 and P = .984, respectively). The double half-racking technique was the stiffest construct, which was significantly greater than the second-stiffest group, the Loop 'n' Tack method with both FiberLink suture (P = .012) and SutureTape (P = .002), which had greater stiffness than the Krakow group (P < .001). The most common failure mode for the Loop 'n' Tack stitch was suture breakage compared with the Krakow and double half-racking methods, where the most common mode of failure was suture pullout from the tendon (P < .001).

Conclusion

Biomechanical testing found that the Loop 'n' Tack techniques had similar ultimate load to failure values when compared with the double half-racking and Krakow methods. Mode-of-failure analysis showed that the Loop 'n' Tack construct typically failed by suture breakage, whereas the other techniques failed by suture pullout.

Clinical Relevance

The Loop 'n' Tack technique allows for secure grasping of tissue without the need for externalization of the tendon. This technique may be beneficial in compromised or poor-quality tissue without reducing overall pullout strength when compared with a standard half-racking or Krakow stitch.