Biceps Tenodesis in Patients Age 35 Years and Younger Yields Favorable Clinical Outcomes With Variable Rates of Return to Sport and Complications: A Systematic Review

Principles of the superior labrum and biceps complex: an expert consensus from the NEER Circle

BACKGROUND

The superior labrum and biceps complex is commonly implicated in shoulder pain and there remains discordance regarding the surgical management of superior labrum anterior to posterior (SLAP) tears. The purpose of this study was to establish an expert consensus regarding the management of superior labrum and biceps complex pathology.

METHODS

The NEER Circle is an organization of shoulder experts recognized for their service to the American Shoulder and Elbow Surgeons (ASES) society. Consensus among 92 identified experts was sought with a series of surveys pertaining to the management of superior labrum and biceps complex (SBC) pathology. The initial survey featured questions crafted to determine the experience of the panel in treating SBC pathology. The second survey was designed to elicit opinions concerning the diagnosis and treatment of SBC pathology. The third survey aimed to establish consensus across 48 scenarios, tasking panelists with categorizing 4 surgical modalities as either preferred, acceptable, or not acceptable. The available options included débridement, SLAP repair, biceps treatment, or a combined repair and biceps treatment. In the final survey, the panelists were tasked with diagnosing SBC pathologies by assessing arthroscopic footage and evaluating treatment options within 45 scenarios. A minimum of 80% agreement was required to attain consensus, designating a treatment as either preferred or unacceptable.

RESULTS

Response rates ranged from 52.2% to 58.7%. Discordance exists regarding aspects of the physical examination, patient history, imaging, nonoperative management, and the surgical approach in SBC injuries. Of the 78 clinical scenarios, 26 reached consensus agreement. Treating the biceps was the favored approach in older, more sedentary patients with evidence of biceps tendinopathy. Performing a SLAP repair was favored in scenarios depicting younger, more active patients with signs of an unstable biceps anchor or mechanical symptoms. A SLAP repair was typically contraindicated in the setting of an older patient, concomitant rotator cuff tear, and/or a prior failed SLAP repair. The management of overhead throwing athletes, particularly those that are professionals, remained controversial, although SLAP repair is generally favored in younger pitchers.

CONCLUSION

The optimal management of superior labrum and biceps complex pathology requires a systematic approach based on the individual's age, occupational demands, and functional requirements. Age was the predominant factor influencing surgical decision making. SLAP repairs are generally favored in younger, active patients, whereas treating the biceps is preferred in lower-demand patients aged >30 years. Little consensus was observed regarding the management of competitive athletes.

Comparable and Improved Clinical Outcomes, Pain Relief, Return to Sport, and Low Popeye Deformity Rates in Inlay Versus Onlay Open Subpectoral Biceps Tenodesis: A Systematic Review

PURPOSE

To directly compare clinical outcomes, including failure rates, incidence of Popeye deformity, and return to sport (RTS)/activity between inlay and onlay fixation techniques specifically for open subpectoral biceps tenodesis.

METHODS

A systematic search of PubMed, EMBASE, and Cochrane Library databases was conducted for studies published between 2014 and 2024. Inclusion criteria consisted of Level I to IV studies in English, reporting clinical outcomes for open subpectoral biceps tenodesis with at least a 2-year follow-up. Data on patient-reported outcome measures, RTS, Popeye deformity, and failure rates were extracted. Risk of bias was assessed using the Methodological Index for Non-Randomized Studies criteria. Statistical analysis was performed to evaluate heterogeneity, and clinical outcomes between fixation techniques were compared using qualitative analysis and 95% confidence intervals.

RESULTS

Fourteen studies with a total of 498 patients (347 in the inlay group, 151 in the onlay group) were included. Postoperative American Shoulder and Elbow Surgeons scores ranged from 78.6 to 95.8, visual analog scale pain scores from 0.25 to 2.6, and Constant-Murley scores from 26.7 to 91.8, with no differences noted between inlay and onlay techniques across these measures on qualitative assessment. RTS rates were similarly comparable, ranging from 62% to 93% across all studies. The incidence of Popeye deformity was low in both groups, ranging from 0% to 7.7% for inlay fixation and from 0% to 6.7% for onlay fixation, with no qualitative differences observed. Heterogeneity in outcomes was attributed to variations in study design and patient populations.

CONCLUSIONS

Both inlay and onlay fixation for open subpectoral biceps tenodesis showed comparable clinical outcomes, similar pain relief, and low rates of Popeye deformity. RTS rates were consistently high across both techniques. The choice of fixation method did not significantly impact the overall results, suggesting that either technique can be used effectively based on surgeon and patient preferences.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I to IV studies.

Biceps Tenodesis and SLAP Repair Show Similar Outcomes in Overhead Throwing Athletes With Baseball Pitchers Exhibiting Worse Rates of Return to Sport: A Systematic Review

PURPOSE

To compare clinical outcomes, return-to-play (RTP) outcomes, and incidence of postoperative complications in overhead throwing athletes with SLAP lesions undergoing SLAP repair versus biceps tenodesis (BT) with minimum 1-year follow-up.

METHODS

Using the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a literature search was conducted on July 9, 2024, by querying PubMed, Scopus, and EMBASE databases. Inclusion criteria consisted of Level I to IV human clinical studies reporting RTP rate, complications, and/or failure rates following SLAP repair versus BT for SLAP lesions in overhead throwing athletes with a minimum 1-year follow-up. Study quality was determined using the Methodological Index for Non-Randomized Studies criteria.

RESULTS

A total of 16 studies from 2005 to 2023, reporting on 547 patients with a mean age ranging from 17.4 to 36.0 years and a mean follow-up ranging from 2.7 to 7.2 years, met inclusion criteria. Twelve studies (n = 459 athletes) reported outcomes following SLAP repair and 5 (n = 88 athletes) following BT. A total of 15 studies reported on baseball players, 8 on softball players, and 2 on handball players. There were 220 pitchers who underwent SLAP repair compared to 34 pitchers who underwent BT. RTP rates for all throwers ranged from 37.5% to 94.7% following SLAP repair and 35.3% to 93.1% following BT. The RTP rate for pitchers and position players following SLAP repair ranged from 40% to 80% and 76.3% to 91.3%, respectively, compared to 16.7% and 80%, respectively, following BT. Complication rates ranged from 0% to 21.8% following SLAP repair compared to 0% following BT. Failure rates and revisions ranged from 7.5% to 12.5% for SLAP repair versus 0% for BT.

CONCLUSIONS

In overhead throwing athletes with SLAP tears, an analysis of 547 patients from 16 studies shows variable RTP rates following SLAP repair and BT, with baseball pitchers having lower RTP rates compared to position players for both procedures. Outcomes for both SLAP repair and BT exhibit massive variability when treating SLAP tears in overhead throwers.

LEVEL OF EVIDENCE

Level IV, systematic review of Level III and IV studies.

Arthroscopic In Situ Biceps Tenodesis Using a Double Loop-and-Tack Knotless Suture Anchor

Arthroscopic biceps tenodesis is a safe and reliable treatment for managing intra-articular biceps tendon pathology. This Technical Note describes an arthroscopic biceps tenodesis technique with a single double loop-and-tack knotless suture anchor.

A qualitative investigation to identify return to sports criteria after shoulder stabilization surgery used by professional team physicians

Purpose: Purpose of this study is to explore currently utilized readiness to return to sports (RTS) criteria after shoulder stabilization surgery used in elite athletes to gain novel insights into the RTS decision making process of professional team physicians.Methods: 19 qualitative semi-structured interviews with professional team physicians were conducted by a single trained interviewer. The interviews were used to identify team physician concepts and themes regarding the criteria used to determine RTS after shoulder stabilization surgery. General inductive analysis and a coding process were used to identify themes and sub-themes arising from the data. A hierarchical approach in coding helped to link themes.Results: We were able to identify five key themes that participating physicians focused on to determine RTS decision making: external influence, objective and subjective criteria, time elapsed since surgery and type of sport. The most important RTS criteria included: range of motion and muscle strength followed by clinical joint stability, time since surgery, ability of sporting movement, psychological readiness, functional testing, absence of pain and allied team support.Conclusion: This study identified several main themes and subordinate minor themes as having the most influence on RTS decision after shoulder surgery. We showed that even among specialized professional team physicians, the main criteria to RTS in these categories were inconsistent necessitating the future development of specific RTS guidelines.

Editorial Commentary: Shoulder Long Head of the Biceps Tendon Transposition Without Tenotomy May Be a Beneficial Augment for Massive Rotator Cuff Tear Repair

Although many surgeons discard the long head of the biceps (LHB) tendon during arthroscopic rotator cuff repairs, several authors have argued that the LHB tendon may serve as a biologic and structural augment for massive repairs. There are multiple benefits of incorporating the LHB tendon autograft in difficult-to-repair massive rotator cuff tears. First, by maintaining the glenoid origin, the tendon likely retains a significant native blood supply, as well as tenocytes, which may support the healing process. In addition, there are several biomechanical benefits. The LHB may act as a dynamic humeral head depressor since it is still attached to the muscular unit distally. The tendon could also serve as a convergence post, while proving robust tissue for the repair. Also, the LHB tendon may decrease undue tension on the repair, bringing us closer to a tension-free repair. Finally, this may be a cost-conscious technique. One concern, requiring additional investigation, is that some surgeons believe the LHB may be a pain generator in patients with rotator cuff tears. One surgeon's trash is another surgeon's treasure.