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

Arthroscopic Subdeltoid Transfer of the Long Head of the Biceps Tendon to the Conjoint Tendon

Surgical intervention is often recommended for refractory pathology affecting the biceps-labrum complex. Tenodesis of the long head of the biceps tendon (LHBT) is a widely accepted treatment modality; however, the optimal technique remains elusive. Arthroscopic subdeltoid transfer of the LHBT to the conjoint tendon, as described in this technical note, continues to demonstrate excellent clinical results. Its advantages include soft tissue-to-soft tissue healing, an advantageous biomechanical construct, and comprehensive evaluation and decompression of the LHBT including the extra-articular bicipital tunnel. The primary limitation of this procedure is the perceived learning curve for safe navigation within the subdeltoid space.

Arthroscopic Pan-Capsular and Transverse Humeral Ligament Release with Biceps Tenodesis for Patients with Refractory Frozen Shoulder

Arthroscopic capsular release allows direct visualization and release of inflamed tissues in refractory frozen shoulder. The reticular neural network in the long head of the biceps tendon (LHBT) and nerve endings of the transverse humeral ligament (THL) might be responsible for shoulder pain. We hypothesized that patients with painful refractory frozen shoulder benefited from pan-capsular release, THL release, and LHBT tenodesis. The LHBT tenodesis decreased the possibility of LHBT instability. The balance of the shoulder joint was maintained after such extensive release. From October 2013 to June 2019, patients with painful refractory frozen shoulder were enrolled consecutively at the same institute. All patients received arthroscopic pan-capsular, THL release, and suprapectoral LHBT tenodesis with a minimum of 2-year follow-up. Preoperative and postoperative shoulder range of motion (ROM), pain visual analog scale (PVAS), subjective shoulder value (SSV), constant score, LHBT score, acromio-humeral distance (AHD), and critical shoulder angle (CSA) were recorded. In total, 35 patients with an average age of 53.1 ± 9 years were enrolled. The average follow-up period was 24 ± 1.5 months. Forward elevation improved from 105.1° ± 17° to 147° ± 12° (p < 0.001), external rotation improved from 24.1° ± 13.3° to 50.9° ± 9.7° (p < 0.001), and internal rotation improved from L3 to T9 (p < 0.001), respectively, at final follow-up. PVAS improved from 7.3 ± 1.1 to 1.8 ± 0.6 (p < 0.001), constant score from 23.4 ± 11 to 80.7 ± 5.2 (p < 0.001), and SSV from 27.7 ± 10.5 to 77.4 ± 3.8, respectively, at follow-up. No differences were found in AHD and CSA after surgery (p = 0.316, and p = 0.895, respectively). Patients with painful refractory frozen shoulder benefited from pan-capsular and THL release. A radiographically balanced shoulder joint was maintained even after such extensive release.

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.

[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.

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.

All-suture anchor and unicortical button show comparable biomechanical properties for onlay subpectoral biceps tenodesis

Hypothesis

The purpose of this study was to biomechanically evaluate onlay subpectoral long head of the biceps (LHB) tenodesis with all-suture anchors and unicortical buttons in cadaveric specimens.

Methods

After evaluation of bone mineral density, 18 fresh-frozen, unpaired human cadaveric shoulders were randomly assigned to 2 groups: One group received an onlay subpectoral LHB tenodesis with 1 all-suture anchor, whereas the other group received a tenodesis with 1 unicortical button. The specimens were mounted in a servo-hydraulic material testing system. Tendons were initially loaded from 5 N to 100 N for 5000 cycles at 1 Hz. Displacement of the repair constructs was observed with optical tracking. After cyclic loading, each specimen was loaded to failure at a rate of 1 mm/s.

Results

The mean displacement after cyclic loading was 6.77 ± 3.15 mm in the all-suture anchor group and 8.41 ± 3.17 mm in the unicortical button group (P = not significant). The mean load to failure was 278.05 ± 38.77 N for all-suture anchor repairs and 291.36 ± 49.69 N for unicortical button repairs (P = not significant). The most common mode of failure in both groups was LHB tendon tearing. There were no significant differences between the 2 groups regarding specimen age (58.33 ± 4.37 years vs. 58.78 ± 5.33 years) and bone mineral density (0.50 ± 0.17 g/cm² vs. 0.44 ± 0.19 g/cm²).

Conclusion

All-suture anchors and unicortical buttons are biomechanically equivalent in displacement and load-to-failure testing for LHB tenodesis. All-suture anchors can be considered a validated alternative for onlay subpectoral LHB tenodesis.

Clinical relevance of the anatomy of the long head bicipital groove, an evidence-based review

Pathology in the bicipital groove can be a source of anterior shoulder pain. Many studies have compared treatment techniques for the long head biceps tendon (LHBT) without showing any clinically significant differences. As the LHBT is closely related to the bicipital groove, anatomical aspects of this groove could also be implicated in surgical outcomes. The aim of this review is to contribute to developing the optimal surgical treatment of LHBT pathology based on clinically relevant aspects of the bicipital groove. Medline/PubMed was systematically searched using key words "bicipital" and "groove" and combinations of their synonyms. Studies reporting on evolution, embryonic development, morphometry, vascularization, innervation, and surgical treatment of the LHBT and the bicipital groove were included. The length of the bicipital groove reported in the included studies ranged from 81.00 mm to 87.33 mm, width from 7.74 mm to 11.60 mm, and depth from 3.70 mm to 6.00 mm. The anatomy of the bicipital groove shows a bottleneck narrowing approximately two-thirds from superior. The transverse humeral ligament can constrain the bicipital groove and could be involved in anterior shoulder pain. When either LHBT tenotomy or tenodesis is performed, routinely releasing the transverse ligament could decrease postoperative anterior shoulder pain, which has frequently been reported in the literature. To avoid the bottle neck narrowing, a location below the bicipital groove may be preferred for biceps tenodesis over a more proximal tenodesis site. Level of evidence: IV.

Injuries of the Biceps and Superior Labral Complex in Overhead Athletes

PURPOSE OF REVIEW

To summarize the current anatomy, biomechanics, presentation, treatment, and outcomes of injuries to the biceps and superior labral complex in overhead athletes.

RECENT FINDINGS

The biceps and superior labral complex is composed of anatomically distinct zones. The inability to accurately diagnose biceps lesions contributes to continued morbidity especially as arthroscopy and advanced imaging fail to fully evaluate the entire course of the biceps tendon. Superior labrum anterior and posterior (SLAP) repair, long head of biceps tenodesis, and tenotomy are the most common operative techniques for surgical treatment of biceps-labral complex (BLC) pathology. Labral repair in overhead athletes has resulted in mixed outcomes for athletes and is best indicated for patients under age 40 years old. Injuries to the BLC are potentially challenging injuries to diagnose and treat, particularly in the overhead athlete. SLAP repair remains the treatment of choice for high-level overhead athletes and patients younger than 40 years of age, while biceps tenodesis and tenotomy are preferred for older patients.

Surgical treatment of shoulder instability with trans-subscapularis transfer of the biceps long tendon

Our objective is to describe the long biceps tendon transfer technique for the treatment of shoulder anterior instability. In this procedure, the long tendon of the biceps brachii is detached from the supraglenoid tubercle and transferred to the anterior edge of the glenoid cavity through a subscapularis tenotomy, reproducing the sling effect and increasing the anterior block. The technique is easy to perform and minimizes the risks of the coracoid process transfer. In conclusion, the transfer of the long tendon of the biceps brachii is an option for the treatment of glenohumeral instability.

Long Head of Biceps Tendon Management: a Survey of the American Shoulder and Elbow Surgeons

BACKGROUND

Management of symptomatic long head of biceps tendon (LHBT) pathology remains a source of debate.

QUESTIONS/PURPOSES

The purpose of this study was to identify consensus trends for the treatment of LHBT pathology among specialists.

METHODS

A survey was distributed to members of the American Shoulder and Elbow Society (ASES), consisting of three sections-demographics, case scenarios, and general LHBT pathology management. Cases presented common clinical scenarios, and surgeons reported their management preferences. Consensus responses were defined as > 50% of participants giving a single response.

RESULTS

One hundred and forty-two of 417 (34%) surgeons completed surveys. Forty-seven percent of questions reached a consensus answer. Biceps tenodesis was the overwhelmingly preferred technique in cases demonstrating LHBT pathology, as compared to tenotomy. No consensus, however, was reached regarding a specific surgical technique for biceps tenodesis. The two most popular techniques were arthroscopic tenodesis to bone and open subpectoral biceps tenodesis. Fellowship-trained arthroscopic surgeons and surgeons with a largely arthroscopic practice were more likely to perform tenodesis arthroscopically.

CONCLUSION

ASES members favored biceps tenodesis over tenotomy for surgical management of LHBT pathology, without consensus regarding a specific surgical technique.

Biceps Tenodesis: Anatomic Tensioning

Biceps tenodesis is a commonly employed surgical intervention for refractory symptoms related to the biceps-labral complex, those intra-articular and those within the extra-articular bicipital tunnel. While a litany of surgical techniques exists, the optimal method for ensuring an anatomic length-tension relationship during tenodesis remains elusive. Appropriate tensioning may limit undesirable outcomes such as cramping or cosmetic deformity. We describe herein our technique as a simple and efficient means to establish patient-specific, anatomic tensioning of the long head of the biceps during tenodesis.

Editorial Commentary: A No-Difference Study That May Make a Difference in the Treatment of Disorders of the Shoulder Biceps Brachii Tendon

Biceps tenodesis for disorders of the biceps brachii is frequently performed; nevertheless the optimum procedure, and particularly the level of tenodesis either above the pectoralis major tendon or inferior to the tendon, is yet to be determined. Both have purported advantages. Studies that do not find a difference in outcomes between the 2 groups in the publishing vernacular are sometimes referred to as no-difference investigations and are slightly less likely to be published, known as publication bias. This may be the rare "no-difference" investigation that makes a difference in the treatment of the biceps brachii.