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

Factors associated with long head of the biceps tendon tear severity and predictive insights for grade II tears in rotator cuff surgery

BACKGROUND

In rotator cuff repair, the long head of the biceps tendon (LHB) is commonly used as graft material. However, factors influencing LHB tear severity are poorly understood, and predicting grade II LHB tears is challenging. This study aimed to identify these factors preoperatively.

METHODS

The demographics, medical parameters, and pain severity of 750 patients who underwent arthroscopic surgery from January 2010 to February 2021 were evaluated to determine the factors associated with LHB tear severity and grade II tears. Both overall and largeto-massive rotator cuff tear (RCT) cohorts underwent ordinal and binary logistic regression analyses. Predictive accuracy for grade II LHB tears was determined using the area under the receiver operating characteristic curve (AUC).

RESULTS

In the overall cohort, high-sensitivity C-reactive protein (hs-CRP) >1 mg/L (P<0.001), subscapularis tear (P<0.001), hypothyroidism (P=0.031), and the tangent sign (P=0.003) were significantly associated with LHB tear severity, and hs-CRP>1 mg/L, subscapularis tear, and Patte retraction degree were significantly associated with grade II LHB tears (P<0.001). In the large-to-massive RCT cohort, hs-CRP>1 mg/L, hypertension, and age ≥50 years (P<0.05) were significantly associated with LHB tear severity, and hs-CRP>1 mg/L (P<0.001) and hypertension (P=0.026) were significantly associated with grade II LHB tears. In both cohorts, hs-CRP >1 mg/L demonstrated good predictive accuracy for grade II LHB tears (AUCs: 0.72 and 0.70).

CONCLUSIONS

Serum hs-CRP >1 mg/L is associated with LHB tear severity and serves as a reliable predictor of grade II LHB tears, facilitating preoperative assessment of the LHB as potential graft material in arthroscopic rotator cuff repair. Level of evidence: III.

Concomitant Biceps Tenodesis Does Not Compromise Arthroscopic Rotator Cuff Repair Outcomes

PURPOSE

To compare outcomes of patients who underwent rotator cuff repair (RCR) with concomitant biceps tenodesis with those who underwent an isolated RCR.

METHODS

Exclusion criteria included previous ipsilateral shoulder surgery, irreparable rotator cuff tears, rotator cuff arthropathy, calcific tendinitis, adhesive capsulitis requiring a capsular release, or advanced osteoarthritis of the glenohumeral joint. Patients were indicated for biceps tenodesis if they had any degree of tendon tearing, moderate-to-severe tenosynovitis, instability, or a significant degenerative SLAP tear. Primary outcome measures included American Shoulder and Elbow Surgeons score, Simple Shoulder Test, EuroQoL 5-Dimension 5-Level visual analog scale, EuroQoL 5-Dimension 5-Level, and a site-specific questionnaire, which focused on surgical expectations, satisfaction, and complications. Multivariate analysis of variance to analyze descriptive statistics and determine significant differences between the patient groups for subjective and objective outcome measures were performed.

RESULTS

There were no significant differences for pain/visual analog scale (0.34 ± 0.09 vs 0.47 ± 0.09, P = .31), American Shoulder and Elbow Surgeons score (96.69 ± 0.87 vs 94.44 ± 0.91, P = .07), and Simple Shoulder Test (11.42 ± 0.17 vs 10.95 ± 0.18, P = .06) between the RCR with concomitant biceps tenodesis and isolated RCR at a minimum of 2 years' postoperatively. This is despite the RCR with concomitant biceps tenodesis group having significantly larger rotator cuff tears (4.25 ± 0.30 cm2 vs 2.80 ± 0.32 cm2, P = .001) than the isolated RCR group.

CONCLUSIONS

This study revealed that concomitant biceps tenodesis does not compromise outcomes when compared with an isolated RCR at 2-year follow-up, despite this group having larger rotator cuff tears.

LEVEL OF EVIDENCE

Level III, retrospective case study.

The association between a rotator cuff tendon tear and a tear of the long head of the biceps tendon: Chart review study

Rotator cuff (RC) and long head of the biceps tendon (LHBT) tears are common shoulder problems presented to the orthopedic clinic. The aim of this study was to assess the association between RC and LHBT tears among a Saudi population sample. A total of 243 patients who were diagnosed with shoulder pain due to RC or LHBT tear between 2016 and 2018 using a magnetic resonance imaging scan were included in this study. Females comprised 66% of the sample, and 59% (n = 143) of the shoulders were on the right side. The mean age of the patients was 58 ± 11 years, ranging from 23 to 88 years. A significant association was detected between the LHBT and RC tears (P < 0.001). Out of 26 cases showing RC and LHBT tears, 81% had a full thickness tear, whereas 19% had a partial tear. The LHBT tears were presented significantly in 48% of cases with at least two completely torn RC compared to 10% in cases with one completely torn RC (P < 0.001). The LHBT tear was significantly observed in shoulders with RC tears including the tendons of subscapularis, supraspinatus, and infraspinatus, but not the teres minor (P < 0.001). Both types of tears were presented significantly in senior patients aged more than 65 years compared to younger patients (P < 0.01). Thus, the LHBT should be assessed carefully in shoulders with more than one RC tear or in chronic cases.

All-Arthroscopic Falciform Portal Biceps Tenodesis

Biceps tenodesis has been proven to be an effective treatment for biceps tendon and superior labral pathology. Many techniques including both open and arthroscopic approaches have been reported. Open techniques afford management of the entire proximal biceps tendon but are limited by wound healing issues, increased bleeding, and increased surgical time. Arthroscopic tenodesis offers benefits in terms of surgical efficiency, cosmesis, and bleeding risk. However, standard arthroscopic tenodesis only addresses intra-articular biceps pathology. In this report we describe an all-arthroscopic biceps tenodesis technique at the suprapectoral region of the humerus using knotless suture anchor fixation.

Effect of extracorporeal shock wave combined with Kinesio taping on upper limb function during individuals with biceps brachii tendinopathy：protocol for a double-blind, randomised controlled trial

INTRODUCTION

Long head of biceps brachii tendinopathy (LHBT) is characterised by persistent pain and disability of shoulder joint, impairing patients' quality of life. Extracorporeal shock wave therapy (ESWT) is a non-invasive treatment, which promotes tissue regeneration and repair. However, ESWT has a side effect that often causes short-term pain and swelling in the treatment area. It is known that the effects of Kinesio taping (KT) on relieving swelling and pain. Due to insufficient clinical evidence from current limited studies, this randomised controlled study aims to explore the effects of ESWT combined with KT on upper limb function during individuals with LHBT.

METHODS AND ANALYSIS

A 2×2 factorial design, double-blind, randomised controlled trial will be conducted. A total of 144 participants will be randomly allocated into one of four groups (KT+ESWT, KT+sham ESWT, sham KT+ESWT or sham KT+sham ESWT) to participate in a 4-week treatment programme. Measurements will be taken at pretreatment (baseline), immediately after treatment and 6 weeks after treatment. The primary endpoint will be the Constant-Murley score (CMS), the secondary endpoints will include the pain Numerical Rating Scale, range of motion, pressure pain threshold and soft tissue hardness of biceps, speed test and global rating of change. Repeated measures analysis of variance will be used to compare differences among the effects of different interventions.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Ethics Committee of the Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine. In addition to international conference reports, findings will be disseminated through international publications in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ChiCTR2100051324.

Shear wave elastography correlates to degeneration and stiffness of the long head of the biceps tendon in patients undergoing tenodesis with arthroscopic shoulder surgery

BACKGROUND

Tendinopathy of the long head of the biceps (LHB) tendon causes degeneration and changes its stiffness. However, a reliable means of diagnosis has not been established. Shear wave elastography (SWE) provides quantitative tissue elasticity measurements. In this study, the relationship of preoperative SWE values with biomechanically measured stiffness and degeneration of the LHB tendon tissue was investigated.

METHODS

LHB tendons were obtained from 18 patients who underwent arthroscopic tenodesis. SWE values were measured preoperatively at 2 sites, proximal to and within the bicipital groove of the LHB tendon. The LHB tendons were detached immediately proximal to the fixed sites and at their superior labrum insertion. Tissue degeneration was histologically quantified using the modified Bonar score. Tendon stiffness was determined using a tensile testing machine.

RESULTS

The SWE values of the LHB tendon were 502.1 ± 113.6 kPa proximal to the groove and 439.4 ± 123.3 kPa within the groove. The stiffness was 39.3 ± 19.2 N/mm. The SWE values displayed a moderate positive correlation with the stiffness proximal to the groove (r = 0.80) and within it (r = 0.72). The SWE value of the LHB tendon within the groove showed a moderate negative correlation with the modified Bonar score (r = -0.74).

CONCLUSIONS

These findings suggest that preoperative SWE values of the LHB tendon correlate moderately positively with stiffness and moderately negatively with tissue degeneration. Therefore, SWE may predict LHB tendon tissue degeneration and changes in stiffness caused by tendinopathy.

Can artificial intelligence help decision-making in arthroscopy? Part 1: Use of a standardized analysis protocol improves inter-observer agreement of arthroscopic diagnostic assessments of the long head of biceps tendon in small rotator cuff tears

INTRODUCTION

Injuries of the long head of biceps (LHB) tendon are common but difficult to diagnose clinically or using imaging. Arthroscopy is the preferred means of diagnostic assessment of the LHB, but it often proves challenging. Its reliability and reproducibility have not yet been assessed. Artificial intelligence (AI) could assist in the arthroscopic analysis of the LHB. The main objective of this study was to evaluate the inter-observer agreement for the specific LHB assessment, according to an analysis protocol based on images of interest. The secondary objective was to define a video database, called "ground truth", intended to create and train AI for the LHB assessment.

HYPOTHESIS

The hypothesis was that the inter-observer agreement analysis, on standardized images, was strong enough to allow the "ground truth" videos to be used as an input database for an AI solution to be used in making arthroscopic LHB diagnoses.

MATERIALS AND METHOD

One hundred and ninety-nine sets of standardized arthroscopic images of LHB exploration were evaluated by 3 independent observers. Each had to characterize the healthy or pathological state of the tendon, specifying the type of lesion: partial tear, hourglass hypertrophy, instability, fissure, superior labral anterior posterior lesion (SLAP 2), chondral print and pathological pulley without instability. Inter-observer agreement levels were measured using Cohen's Kappa (K) coefficient and Kappa Accuracy.

RESULTS

The strength of agreement was moderate to strong according to the observers (Kappa 0.54 to 0.7 and KappaAcc from 86 to 92%), when determining the healthy or pathological state of the LHB. When the tendon was pathological, the strength of agreement was moderate to strong when it came to a partial tear (Kappa 0.49 to 0.71 and KappaAcc from 85 to 92%), fissure (Kappa -0.5 to 0.7 and KappaAcc from 36 to 93%) or a SLAP tear (0.54 to 0.88 and KappaAcc from 90 to 97%). It was low for unstable lesion (Kappa 0.04 to 0.25 and KappaAcc from 36 to 88%).

CONCLUSION

The analysis of the LHB, from arthroscopic images, had a high level of agreement for the diagnosis of its healthy or pathological nature. However, the agreement rate decreased for the diagnosis of rare or dynamic tendon lesions. Thus, AI engineered from human analysis would have the same difficulties if it was limited only to an arthroscopic analysis. The integration of clinical and paraclinical data is necessary to improve the arthroscopic diagnosis of LHB injuries. It also seems to be an essential prerequisite for making a so-called "ground truth" database for building a high-performance AI solution.

LEVEL OF EVIDENCE

III; inter-observer prospective series.

Outcomes of Biceps Tenodesis Variations With Concomitant Rotator Cuff Repair: A Multicenter Database Analysis

Background

Studies to date comparing biceps tenodesis methods in the setting of concomitant rotator cuff repair (RCR) have demonstrated relatively equivalent pain and functional outcomes.

Purpose

To compare biceps tenodesis constructs, locations, and techniques in patients who underwent RCR using a large multicenter database.

Study Design

Cohort study; Level of evidence, 3.

Methods

A global outcome database was queried for patients with medium- and large-sized tears who underwent biceps tenodesis with RCR between 2015 and 2021. Patients ≥18 years of age with a minimum follow-up of 1 year were included. The American Shoulder and Elbow Surgeons, Single Assessment Numeric Evaluation, visual analog scale for pain, and Veterans RAND 12-Item Health Survey (VR-12) scores were compared at 1 and 2 years of follow-up based on construct (anchor, screw, or suture), location (subpectoral, suprapectoral, or top of groove), and technique (inlay or onlay). Nonparametric hypothesis testing was used to compare continuous outcomes at each time point. The proportion of patients achieving the minimal clinically important difference (MCID) at the 1- and 2-year follow-ups were compared between groups using chi-square tests.

Results

A total of 1903 unique shoulder entries were analyzed. Improvement in VR-12 Mental score favored anchor and suture fixations at 1 year of follow-up (P = .042) and the onlay tenodesis technique at 2 years of follow-up (P = .029). No additional tenodesis comparisons demonstrated statistical significance. The proportion of patients with improvement exceeding the MCID did not differ based on tenodesis methods for any outcome score assessed at the 1- or 2-year follow-up.

Conclusion

Biceps tenodesis with concomitant RCR led to improved outcomes regardless of tenodesis fixation construct, location, or technique. A clear optimal tenodesis method with RCR remains to be determined. Surgeon preference and experience with various tenodesis methods as well as patient clinical presentation should continue to guide surgical decision-making.

Subpectoral, Suprapectoral, and Top-of-Groove Biceps Tenodesis Procedures Lead to Similar Good Clinical Outcomes: Comparison of Biceps Tenodesis Procedures

Purpose

To determine whether there is a difference in clinical results among open subpectoral (SB), arthroscopic low-in-groove suprapectoral (SP), and arthroscopic top-of-groove (TOG) locations in terms of patient-reported outcome measures for biceps tenodesis (BT) procedures using a global, self-reporting registry.

Methods

We identified patients who underwent BT surgery in the Surgical Outcomes System registry. The inclusion criteria were isolated primary surgical procedures for BT, excluding patients with rotator cuff and labral repairs. Additional search requirements included repair location and 100% compliance with pretreatment and 2-year follow-up surveys. This study measured clinical outcomes comparing the 3 aforementioned techniques using the American Shoulder and Elbow Surgeons (ASES) score, visual analog scale (VAS) pain score, and Single Assessment Numeric Evaluation (SANE) score before treatment and at 3 months, 6 months, 1 year, and 2 years postoperatively. In addition, postoperative VAS pain scores were collected at 2 and 6 weeks. Statistical analysis was conducted using analysis of variance (Kruskal-Wallis test) and the Wilcoxon test.

Results

A total of 1,923 patients from the Surgical Outcomes System registry qualified for the study; of these, 879 underwent the SB technique, 354 underwent the SP technique, and 690 underwent the TOG technique. There was no statistically significant difference in the demographic characteristics among the groups except that the TOG group was older: 60.76 years versus 54.56 years in the SB group and 54.90 years in the SP group (P < .001). In all groups, the ASES score statistically improved from before treatment (mean, 49.29 ± 0.63) to 2 years postoperatively (mean, 86.82 ± 0.80; P < .05). There were no statistically significant differences among the 3 groups in the VAS, ASES, and SANE scores at all time points (P > .12) except for the VAS score at 1 year (P = .032) and the ASES score at 3 months (P = .0159). At 1 year, the mean VAS score in the SB group versus the TOG group was 1.146 ± 1.27 versus 1.481 ± 1.62 (P = .032), but the minimal clinically important difference (MCID) was not met. The 3-month ASES Index scores in the SB, SP, and TOG groups were 68.991 ± 18.64, 66.499 ± 17.89, and 67.274 ± 16.9, respectively (P = .0159), and similarly, the MCID was not met. At 2 years, the ASES scores in the SB, SP, and TOG groups improved from 49.986 ± 18.68, 49.54 ± 16.86, and 49.697 ± 7.84, respectively, preoperatively to 86.00 ± 18.09, 87.60 ± 17.69, and 86.86 ± 16.36, respectively, postoperatively (P > .12).

Conclusions

The SB, SP, and TOG BT procedures each resulted in excellent clinical improvement based on patient-reported outcome measures from a global registry. On the basis of the MCID, no technique was clinically superior to the other techniques in terms of VAS, ASES, or SANE scores at any time point up to 2 years.

Level of Evidence

Level III, retrospective comparative study.

Are the Pathologic Features of Enthesopathy, Tendinopathy, and Labral and Articular Disc Disease Related to Mucoid Degeneration? A Systematic Review

BACKGROUND

Tendinopathy, enthesopathy, labral degeneration, and pathologic conditions of the articular disc (knee meniscus and ulnocarpal) are sometimes described in terms of inflammation or damage, while the histopathologic findings are often consistent with mucoid degeneration. A systematic review of the histopathology of these structures at diverse locations might reconceptualize these diseases as expected aspects of human aging. The potential benefits of this evolution might include healthier patient and clinician mindsets as well as a reduced likelihood of overdiagnosis and overtreatment resulting from greater awareness of base rates of pathology.

QUESTION/PURPOSE

In this systematic review of studies of surgical specimens, we asked: Are there are any differences in the histopathologic findings of structural soft tissue conditions (mucoid degeneration, inflammation, and vascularity) by anatomic site (foot, elbow, or knee) or structure (tendon body, muscle or tendon origin or insertion [enthesis], labrum, or articular disc)?

METHODS

Studies between 1980 and 2021 investigating the histopathologic findings of specimens from surgery for trigger digit, de Quervain tendinopathy, plantar fasciitis, lateral and medial elbow enthesopathy, rotator cuff tendinopathy, posterior tibial tendinopathy, patellar tendinopathy, Achilles tendinopathy, or disease of the hip labrum, ulnocarpal articular disc, or knee meniscus were searched for in the PubMed, EMBASE, and CINAHL databases. Inclusion criteria were the prespecified anatomic location or structure being analyzed histologically and any findings described with respect to inflammation, vascularity, or mucoid degeneration. Studies were excluded if they were nonhuman studies or review articles. Search terms included "anatomy," "pathology," and "histopathology." These terms were coupled with anatomic structures or disorders and included "trigger finger," "de Quervain," "fasciitis, plantar," "tennis elbow," "rotator cuff tendinopathy," "elbow tendinopathy," "patellar tendonitis," "posterior tibial tendon," and "triangular fibrocartilage." This resulted in 3196 studies. After applying the inclusion criteria, 559 articles were then assessed for eligibility according to our exclusion criteria, with 52 eventually included. We recorded whether the study identified the following histopathologic findings: inflammatory cells or molecular markers, greater than expected vascularity (categorized as quantitative count, with or without controls; molecular markers; or qualitative judgments), and features of mucoid degeneration (disorganized collagen, increased extracellular matrix, or chondroid metaplasia). In the absence of methods for systematically evaluating the pathophysiology of structural (collagenous) soft tissue structures and rating histopathologic study quality, all studies that interpreted histopathology results were included. The original authors' judgment regarding the presence or absence of inflammation, greater than expected vascularity, and elements of mucoid degeneration was recorded along with the type of data used to reach that conclusion.

RESULTS

Regarding differences in the histopathology of surgical specimens of structural soft tissue conditions by anatomic site, there were no differences in inflammation or mucoid degeneration, and the knee meniscus was less often described as having greater than normal vascularity. There were no differences by anatomic structure. Overall, 20% (10 of 51) of the studies that investigated for inflammation reported it (nine inflammatory cells and one inflammatory marker). Eighty-three percent (43 of 52) interpreted increased vascularity: 40% (17 of 43) using quantitative methods (14 with controls and three without) and 60% (26 of 43) using imprecise criteria. Additionally, 100% (all 52 studies) identified at least one element of mucoid degeneration: 69% (36 of 52) reported an increased extracellular matrix, 71% (37 of 52) reported disorganized collagen, and 33% (17 of 52) reported chondroid metaplasia.

CONCLUSION

Our systematic review of the histopathology of diseases of soft tissue structures (enthesopathy, tendinopathy, and labral and articular disc) identified consistent mucoid degeneration, minimal inflammation, and imprecise assessment of relative vascularity; these findings were consistent across anatomic sites and structures, supporting a reconceptualization of these diseases as related to aging (senescence or degeneration) rather than injury or activity.

CLINICAL RELEVANCE

This reconceptualization supports accommodative mindsets known to be associated with greater comfort and capability. In addition, awareness of the notable base rates of structural soft tissue changes as people age might reduce overdiagnosis and overtreatment of incidental, benign, or inconsequential signal changes and pathophysiology.

Ultrasound-guided injection of the long head of the biceps tendon sheath with concomitant subacromial bursa injection through the same needlestick

Sonography and specific shoulder positions allow for injections into both the long head of the biceps tendon sheath (LHBTS) and the subacromial space (SS) with one needlestick. We validated this technique using cadavers. An experienced proceduralist injected latex solution into 12 unembalmed cadaveric shoulders, aiming for the LHBTS and SS, using an ultrasound-guided injection technique that employs a single-needle entry point. An experienced surgeon dissected each specimen and graded latex location as: (1) completely accurate (in both the SS and LHBTS); (2) partially accurate (in either the SS or LHBTS); (3) accurate with overflow (in both locations, but also elsewhere); (4) partially accurate with overflow (in either location, but also somewhere else); or (5) completely inaccurate (no latex in either location). All 12 ultrasound-guided injections using the technique accurately placed latex into both LHBTS and SS (100% accuracy). Latex was also found in adjacent regions after two (17%) injections: one within the shoulder joint and one within the deltoid musculature. This newly described technique allows highly accurate access to the LHBTS and SS with single-needle entry. This technique could become a favored alternative to subjecting patients to two needlesticks and preparing separate injections to address often concomitant pathologies.

The long head of biceps at the shoulder: a scoping review

BACKGROUND

This review aimed to explore the available literature to update our understanding of the long head of biceps (LHB) at the shoulder. Synthesise our findings to identify emergent themes and knowledge gaps to inform future research and management directions.

METHODS

PubMed, Embase, Cinahl, SportDiscus, CENTRAL, and Web of Science were searched from inception to 31st December 2021. Articles were included if they referenced adult participants > 18 years of age and were written in English.

RESULTS

214 articles were included in the final analysis, and results were categorised into six emergent themes: (1) Anatomy - Normal anatomical variation of the biceps from aberrant origins, third and fourth accessory heads, and an absence of the LHB tendon (LHBT) are not necessarily benign, with shoulder pain and instability a commonly reported theme. (2) Function - Bicep's role in glenohumeral elevation and stability in healthy shoulders is minimal. In contrast, LHB has a more significant role in shoulder stability and humeral head depression in subjects with rotator cuff failure or an absent LHBT. (3) Pathology - There is an association between LHB tendinopathy, rotator cuff disease, LHBT instability and occult rotator cuff tears. Early recruitment and hyperactivity of the LHB in subjects with symptomatic rotator cuff tears and instability suggest a potential compensatory role. (4) Assessment - The limited diagnostic utility of special orthopaedic tests in assessing LHBT pathology was a consistent theme. The utility of magnetic resonance imaging and ultrasound to identify full-thickness tendon tears and instability of the LHBT was moderate to high. However, the utility of clinical tests and imaging may be underestimated due to arthroscopy's limitations in fully visualising the proximal LHBT. (5) Non-Surgical Management - Ultrasound-guided injections into the biceps sheath show greater accuracy and patient outcomes than blinded injections; however, the entry of injectate into the intraarticular glenohumeral joint may have unwanted complications. (6) Surgical management - For the surgical management of biceps pathology with or without rotator cuff pathology, both biceps tenodesis and tenotomy report similar improvements in pain without any significant adverse effect on strength or function. Tenodesis favoured higher overall constant scores and a lower incidence of Popeye deformity and cramping arm pain, with tenotomy trending to be more cost and time effective. For patients with a healthy LHBT, rotator cuff repair with adjunctive tenodesis or tenotomy fails to provide additional clinical improvements compared to rotator cuff repair in isolation.

CONCLUSIONS

The scoping review highlights the variability of biceps anatomy, which is not necessarily benign and suggests a minimal role of the LHB in shoulder elevation and stability in healthy individuals. In contrast, individuals with rotator cuff tears experience proximal humeral migration and demonstrate hyperactivity of the LHB, suggesting a potential compensation role. The observed prevalence of LHBT pathology with rotator cuff tears is well established; however, the cause-and-effect relationship between LHBT pathology and rotator cuff disease is undetermined. The diagnostic utility of clinical tests and imaging to exclude LHBT pathology may be understated due to the limitations of arthroscopy to visualise the proximal LHBT fully. Rehabilitation programs for the LHB are understudied. Similar post-surgical clinical outcomes are observed for tenodesis and tenotomy for biceps and rotator cuff-related shoulder pain. Subjects undergoing biceps tenodesis are less likely to have cramping arm pain and a Popeye deformity than patients undergoing biceps tenotomy. The significance of routine surgical removal of the LHBT and sequelae on rotator cuff tear progression to failure and long-term shoulder function is unknown, and further research is required.

PRE-REGISTRATION

OSF: https://osf.io/erh9m.

Nonoperative Treatment of the Biceps-Labral Complex

The long head of the biceps and superior labrum should be evaluated as an interdependent functional unit. A focused patient history and physical examination including multiple provocative tests should be performed alongside advanced imaging studies to obtain an accurate diagnosis. Nonoperative treatment modalities including nonsteroidal anti-inflammatory drugs, glucocorticoid injections, and a standardized physical therapy regimen should be exhausted before operative intervention. Significant improvements in pain, functional outcomes, and quality of life are achieved in patients treated nonoperatively. Although these outcomes are less consistent for overhead athletes, return to play and performance metrics seem comparable to those who undergo surgery.

Biceps Tenodesis Better Improves the Shoulder Function Compared with Tenotomy for Long Head of the Biceps Tendon Lesions: A Meta-Analysis of Randomised Controlled Trials

PURPOSE

Surgical options for long head of the biceps tendon (LHBT) lesions include tenotomy and tenodesis. This study aims to determine the optimal surgical strategy for LHBT lesions with updated evidence from randomised controlled trials (RCTs).

METHODS

Literature was retrieved from PubMed, Cochrane Library, Embase and Web of Science on 12 January 2022. Randomised controlled trials (RCTs) comparing the clinical outcomes of tenotomy and tenodesis were pooled in the meta-analyses.

RESULTS

Ten RCTs with 787 cases met the inclusion criteria, and were included in the meta-analysis. Constant scores (MD, -1.24; p = 0.001), improvement of Constant scores (MD, -1.54; p = 0.04), Simple Shoulder Test (SST) scores (MD, -0.73; p = 0.03) and improvement of SST (p < 0.05) were significantly better in patients with tenodesis. Tenotomy was associated with higher rates of Popeye deformity (OR, 3.34; p < 0.001) and cramping pain (OR, 3.36; p = 0.008]. No significant differences were noticed between tenotomy and tenodesis regarding pain (p = 0.59), American Shoulder and Elbow Surgeons (ASES) score (p = 0.42) and its improvement (p = 0.91), elbow flexion strength (p = 0.38), forearm supination strength (p = 0.68) and range of motion of shoulder external rotation (p = 0.62). Subgroup analyses showed higher Constant scores in all tenodesis types and significantly larger improvement of Constant scores regarding intracuff tenodesis (MD, -5.87; p = 0.001).

CONCLUSIONS

According to the analyses of RCTs, tenodesis better improves shoulder function in terms of Constant scores and SST scores, and reduces the risk of Popeye deformity and cramping bicipital pain. Intracuff tenodesis might offer the best shoulder function as measured with Constant scores. However, tenotomy and tenodesis provide similar satisfactory results for pain relief, ASES score, biceps strength and shoulder range of motion.

Arthroscopic Suprapectoral Biceps Tenodesis: The Best of Both Worlds

Biceps tendinopathy and superior labrum anterior posterior lesions are a common source of shoulder pain and disability and can be effectively treated with biceps tenodesis. There are a variety of open and arthroscopic tenodesis techniques, but no one technique has demonstrated superiority. Arthroscopic techniques often disregard the extra-articular portions of the biceps tendon as a potential source of pain. Open techniques address this concern; however, they can be associated with wound complications, increased blood loss, nerve injury, and disruptions to surgical workflow. Here, we describe an all arthroscopic tenodesis technique at the suprapectoral zone of the tendon. This method addresses extra-articular sources of pain, while limiting the potential pitfalls of open surgery.

Flexion-extension-supination test compared to arthroscopic findings of biceps long head pathology: A physical examination that reflect anatomical evolution of human shoulder girdle

The accuracy of physical examination for diagnosing lesions of the long head of the biceps tendon (LHBT) remains unsatisfactory. The purpose of this study was to describe a new diagnostic test, the Flexion-Extension-Supination (FES) test for diagnosing lesions of the long head of biceps tendon. A prospective study of 162 patients was performed to evaluate the diagnostic value of FES test. All the participants were evaluated on the basis of their clinical presentation, physical examination (FES test), radiologic findings and arthroscopic examination. Shoulder arthroscopy findings were used as the gold standard. To reduce the omission of the hidden lesion, LHBT was checked at the intra- and the extraarticular side via arthroscopic examination. Surgical findings related to biceps pathology were as follows: rotator cuff tears, 89.5% (145/162); subacromial impingement, 8.6% (14/162); and biceps tendinitis, 1.9% (3/162). The prevalence of biceps pathology was 77.2% (125/162) of all arthroscopic procedures. No significant differences for LHBT lesions were observed between the FES test and the arthroscopic findings (P = .850). The interrater reliability of the FES test was 0.747. After excluding inconclusive results between examiners, the sensitivity, specificity, positive predictive value, and negative predictive value of the FES test were 87.9%, 66.7%, 82.9%, and 63.2%, respectively. Positive and negative likelihood ratios were 2.67 and 0.18, respectively. The maneuvers of the FES test irritate intra- and extraarticular lesion of LHBT. The FES test is a reproducible and reliable test that can be used during physical examinations to evaluate patients with LHBT lesions.

3D imaging has good specificity but poor sensitivity for the diagnosis of pathologies of the long head of the biceps: a systematic review and meta-analysis

PURPOSE

To systematically review and meta-analyse the literature to determine which three-dimensional (3D) imaging modality provides the best diagnostic accuracy to detect pathologies of the long head of the biceps tendon (LHBT).

MATERIALS AND METHODS

A search was performed on PubMed, Embase^®, and Cochrane. Studies that compared the diagnostic accuracy of 3D imaging modalities versus arthroscopy for the assessment of LHBT pathologies were included. Studies assessing superior labral anterior posterior (SLAP) lesions were excluded.

RESULTS

Fifteen studies were included; nine were eligible for meta-analysis. Six studies on instability indicated a sensitivity of 0.68 (CI 0.46-0.84) and specificity of 0.76 (CI 0.68-0.82). Four studies on full-thickness tears indicated a sensitivity of 0.56 (CI 0.28-0.81) and specificity of 0.97 (CI 0.93-0.99). Four studies on partial-thickness tears indicated a sensitivity of 0.52 (CI 0.20-0.82) and specificity of 0.64 (CI 0.25-0.91). Two studies on any tear indicated a sensitivity of 0.58 (CI 0.28-0.83) and specificity of 0.99 (CI 0.93-1.00). Only one study on other pathologies indicated a sensitivity of 0.61 and specificity of 0.84.

CONCLUSION

To diagnose LHBT pathologies, 3D imaging modalities overall have low-to-moderate sensitivity, but high-to-excellent specificity. The consistency in reported sensitivity is generally poor, while the consistency and reported specificity is good for the detection of instability, full-thickness tears and any tear, but poor for the detection of partial-thickness tears. 3D imaging may be adequate to rule out LHBT pathologies, but are not sufficiently reliable to confirm the presence of such pathologies.

LEVEL OF EVIDENCE

III.

mRNA and long non-coding RNA expression profiles of rotator cuff tear patients reveal inflammatory features in long head of biceps tendon

Background

This study aimed to identify the differentially expressed mRNAs and lncRNAs in inflammatory long head of biceps tendon (LHBT) of rotator cuff tear (RCT) patients and further explore the function and potential targets of differentially expressed lncRNAs in biceps tendon pathology.

Methods

Human gene expression microarray was made between 3 inflammatory LHBT samples and 3 normal LHBT samples from RCT patients. GO analysis and KEGG pathway analysis were performed to annotate the function of differentially expressed mRNAs. The real-time quantitative reverse transcription-polymerase chain reaction (qRT-PCR) was admitted to verify their expression. LncRNA-mRNA co-expression network, cis-acting element, trans-acting element and transcription factor (TF) regulation analysis were constructed to predict the potential molecular regulatory mechanisms and targets for LHB tendinitis.

Results

103 differentially expressed lncRNAs and mRNAs, of which 75 were up-regulated and 28 were down-regulated, were detected to be differentially expressed in LHBT. The expressions of 4 most differentially expressed lncRNAs (A2MP1, LOC100996671, COL6A4P, lnc-LRCH1-5) were confirmed by qRT-PCR. GO functional analysis indicated that related lncRNAs and mRNAs were involved in the biological processes of regulation of innate immune response, neutrophil chemotaxis, interleukin-1 cell response and others. KEGG pathway analysis indicated that related lncRNAs and mRNAs were involved in MAPK signaling pathway, NF-kappa B signaling pathway, cAMP signaling pathway and others. TF regulation analysis revealed that COL6A4P2, A2MP1 and LOC100996671 target NFKB2.

Conclusions

LlncRNA-COL6A4P2, A2MP1 and LOC100996671 may regulate the inflammation of LHBT in RCT patients through NFKB2/NF-kappa B signaling pathway, and preliminarily revealed the pathological molecular mechanism of tendinitis of LHBT.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12920-022-01292-y.

Physical Therapy Interventions for the Management of Biceps Tendinopathy: An International Delphi Study

Background

Shoulder pain related to the long head of the biceps tendon (LHBT) tendinopathy can be debilitating and difficult to treat especially in athletes who often elect for surgical intervention. Conservative management is recommended but there are limited established guidelines on the physical therapy (PT) management of the condition.

Hypothesis/Purpose

The purpose of this study was to establish consensus on conservative, non-surgical physical therapy interventions for individuals with LHBT tendinopathy using the Delphi method approach.

Study Design

Delphi Study.

Methods

Through an iterative process, experts in the PT field rated their agreement with a list of proposed treatment interventions and suggested additional interventions during each round. Agreement was measured using a four-point Likert scale. Descriptive statistics including median and percentage agreement were used to measure agreement. Data analysis at the end of Round III produced, by consensus, a list of PT interventions recommended for the management of individuals with LHBT tendinopathy. Consensus was defined as an a priori cutoff of ≥75% agreement.

Results

The respondent group included 29 international experts in the PT management of individuals with shoulder pain. At the conclusion of the study 61 interventions were designated as recommended based on consensus amongst experts and 9 interventions were not recommended based on the same criteria, 15 interventions did not achieve consensus.

Conclusion

There is a lack of well-defined, PT interventions used to treat LHBT tendinopathy. Expert respondents reached consensus on multimodal interventions including exercise, manual therapy and patient education to manage LHBT tendinopathy.

Level of Evidence

5.

Prediction of Bilaterality in Patients With 1 Posterosuperior Rotator Cuff Tear

BACKGROUND

In patients with a known unilateral posterosuperior rotator cuff tear (PSRCT), the ability to predict a contralateral PSRCT may assist in earlier diagnosis and improved patient outcomes.

PURPOSE

To determine factors associated with bilateral PSRCT and their most predictive combinations using a nonhospitalized general population.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

This study involved 736 individuals (n = 1472 shoulders) drawn from a rural cohort. PSRCT was diagnosed using magnetic resonance imaging. Symptoms of the contralateral shoulder were not considered. The demographic, physical, social, metabolic, and imaging factors, as well as comorbidities, were evaluated using logistic regression analysis. Cutoff values for the significantly associated variables obtained from multivariable logistic regression analysis were calculated using the receiver operating characteristic (ROC) curve. The areas under the ROC curve (AUCs) of the combinations of significantly associated variables were compared using the DeLong method to determine the combination most predictive of bilateral PSRCT. The likelihood ratio and the posttest probability for each of the combinations were assessed.

RESULTS

Age ≥61 years, manual labor, critical shoulder angle (CSA) ≥35°, retraction degree of Patte ≥ grade 2, biceps tendon injury, and metabolic syndrome were significantly associated with bilateral PSRCT in multivariable analysis (P < .001). The 1-by-1 combination of any 4 of the 6 associated factors significantly increased the AUC of any smaller combinations of those 6 factors (P < .001). The AUCs of the 4-somes were all similar (P ≥ .383) and were not significantly increased by further addition of identified associated factors (P ≥ .422). Any combination of 4 of the 6 associated factors was highly predictive of bilateral PSRCT, each having a minimum AUC of 0.70, a likelihood ratio of >10, and a minimum posttest probability of 80%.

CONCLUSION

Unilateral PSRCT, accompanied by any 4 of the variables of age ≥61 years, manual labor, CSA ≥35°, retraction degree of Patte ≥ grade 2, biceps tendon injury, and metabolic syndrome, is highly predictive of PSRCT in the other shoulder.

A biomechanical study on the effect of long head of biceps tenotomy on supraspinatus load and humeral head position during shoulder abduction

INTRODUCTION

The purpose of this study was to determine the effect of biceps tendon tenotomy on the load of the supraspinatus tendon/muscle complex during abduction of the arm from 0° to 15°.

METHODS

Eleven fresh frozen human cadaver shoulders (6 males, 5 females, age ranged 44-88 years, mean upper extremity weight 2.96 ± 0.56 kg) were included. The specimens were sequentially mounted onto a custom-made fixture attached to a pulley system and load cell. The pulley system was used to pull the supraspinatus tendon/muscle complex along its fiber directions to abduct the arm to 15°. Abduction angles were recorded with a digital inclinometer. Two conditions were tested: (1) long head biceps tendon (LHBT) intact and in normal anatomical position; (2) LHBT cut within the bicipital groove. Qualitative visual inspection of humeral head displacement during abduction was also included. Descriptive statistics were calculated. The Shapiro-Wilk test was used to establish normal data distribution, and the paired t-test was used to compare the 2 conditions.

RESULTS

For the intact condition (LHBT intact), the mean load was 45.71 ± 21.04 N. For the biceps tenotomy test, the load measured 41.37 ± 23.43 N. These differences were not significant (P = .1480). In the tenotomy condition, the humeral head initially displaced inferior, and with initiation of abduction, the humeral head translated superior to its normal position.

CONCLUSION

The results suggest that the LHBT has no critical role with initial abduction of the arm. Furthermore, the LHBT does not appear to increase loads required for the supraspinatus muscle/tendon complex to perform the same action of abduction.

The role of elbow positioning on arthroscopic assessment of the long head of biceps tendon in the beach chair position

Background

Tendinopathy of the long head of biceps (LHB) tendon is a common cause of anterior shoulder pain and dysfunction. The extra‐articular portion within the bicipital groove undergoes frequent load and friction during shoulder movements and pathology within this area is frequently missed during arthroscopic assessment.

Methods

We quantified the arthroscopically assessable length of tendon within the shoulder in 14 consecutive patients undergoing subpectoral biceps tenodesis. After biceps tenotomy at the superior labrum, the tagged tendon was maximally tensioned and marked at the biceps outlet with the elbow in extension and flexion. The distance in distance between the two were measured.

Results

Mean distance from the superior labral insertion of the biceps to the outlet was 16.4 ± 4.1 mm (range, 11–25). With tension on the biceps with elbow extension, the mean measurable distance was 31.3 ± 6.7 mm (range, 19–45). With elbow flexion, this increased to 39.5 ± 5.9 mm (range, 25–52). Mean increase in visible tendon length was 8.2 ± 4.3 mm (range, 5–21) (p = 0.002).

Conclusion

Elbow flexion results in an average increase of 26.2% more extra‐articular tendon visualized at arthroscopy. Therefore, we believe that elbow flexion is a useful adjunct, especially when performed in conjunction with techniques that pull the tendon into the joint, thus allowing for more complete arthroscopic assessment of the LHB, increasing detection of symptomatic biceps tendonitis.

Level of evidence: Level IV.

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.

Usefulness of ultrasound in diagnosing long head of the biceps tendon malposition in patients with rotator cuff tears

PURPOSE

This study aimed to determine the role of preoperative shoulder ultrasonography (SUS) in detecting positional abnormalities of the long head of the biceps tendon (LHBT) and predicting subscapularis (SSC) tears in patients with rotator cuff injuries.

METHODS

A total of 331 patients (365 shoulders) who had undergone arthroscopic shoulder surgery for the treatment of rotator cuff tears were included in the study. Their preoperative SUS and magnetic resonance imaging (MRI) findings were examined retrospectively to assess the presence of LHBT abnormalities at the bicipital groove. Using arthroscopic findings as the standard of reference, the sensitivity, specificity, and diagnostic accuracy of SUS and MRI were calculated for detection of LHBT malposition. Furthermore, the correlation between SSC rupture and preoperative LHBT condition was evaluated by MRI and SUS.

RESULTS

LHBT malposition was preoperatively diagnosed with a sensitivity of 92%, specificity of 90%, and accuracy of 91% with SUS, and a sensitivity of 74%, specificity of 84%, and accuracy of 80% with MRI. Preoperative SUS was significantly superior to MRI in terms of sensitivity, specificity, and accuracy (p < 0.001 each). Further, the preoperative SUS LHBT findings could predict well the presence or absence of intraoperative SSC rupture (odds ratio: 1.73, p < 0.001).

CONCLUSION

SUS is a useful diagnostic modality for preoperative detection of LHBT malposition and prediction of SSC tears in patients with rotator cuff tears.

Rotator cuff repair with or without proximal end detachment for long head of the biceps tendon tenodesis

Background

Rotator cuff tears cause pathologies of the long head of the biceps tendon (LHBT). One of the surgical treatments for such a tear is LHBT tenodesis to the humerus. This study aims to compare simultaneous rotator cuff repair and LHBT tenodesis with or without detachment of the proximal end of the LHBT (PELHBT) from its site of adhesion to the glenoid.

Methods

This retrospective study involved patients affected by LHBT pathology with rotator cuff tear. The patients were divided into two groups, with or without PELHBT detachment from the glenoid. Therapeutic outcomes were investigated by evaluation of patient satisfaction, pain based on visual analog scale, shoulder function based on Constant score and simple shoulder test, and biceps muscle strength based on the manual muscle testing grading system before surgery, at 6 months, and at the final visit after surgery.

Results

Groups 1 and 2 comprised 23 and 26 patients, respectively, who showed no significant differences in demographic characteristics (p>0.05). Shoulder function, biceps muscle strength, pain, and satisfaction rate improved over time (p<0.05) but were not significantly different between the two groups (p>0.05). No post-surgical complication was found in either group.

Conclusions

There was no difference in final outcomes of tenodesis with or without detachment of the PELHBT from the supraglenoid tubercle. Such tendon detachment is not necessary.

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

Background

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

Methods

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

Results

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

Conclusion

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

Supplementary Information

The online version contains supplementary material available at 10.1007/s00264-022-05338-9.

Histopathology of long head of biceps tendon removed during tenodesis demonstrates degenerative histopathology and not inflammatory changes

Background

The aim of this study is to describe and quantitatively analyze the histopathology of proximal long head biceps (LHB) tendinopathy in patients who have undergone LHB tenodesis. The hypothesis is that severe histopathologic changes of the LHB tendon (LHBT) will most likely be reflected with improved postoperative clinical outcomes.

Methods

The study included patients with isolated LHB tendinopathy or LHB tendinopathy associated with concomitant shoulder pathologies. All had failed conservative treatment (12 months) and had a positive pain response (> 50% reduction) pre-operatively after LHB tendon injection with local anesthetic. All underwent biceps tenodesis procedure between 2008 and 2014. Tendon specimens were collected and histologically analyzed with the semi-quantitative Bonar scoring system. Minimum follow-up time was 1 year. A subset of patients was retrospectively reviewed postoperatively and evaluated employing visual analogue score (VAS), short form survey (SF-12), American Shoulder and Elbow Surgeon (ASES) score, Disability of Arm, Shoulder and Hand (DASH) score, and Oxford Shoulder Score (OSS) and postoperative return to work status.

Results

Forty-five biceps tendon specimens were obtained from 44 patients (mean age 50 ± 9.6 years). Histopathological analyses demonstrated advanced degenerative changes with myxoid degeneration and marked collagen disorganization. Minimal inflammation was identified. There were no regional differences in histopathological changes. Clinical outcomes did not correlate significantly with severity of histopathologic changes.

Conclusions

This study confirms that LHBT specimens in patients undergoing tenodesis demonstrate with the use of the Bonar score histopathologic changes of chronic degeneration and not inflammation. The correct histopathologic terminology for this process is LHB tendinosis. The histopathological changes appear uniform throughout the entire length of the LHBT which may inform the nature of the procedure performed.

Management of proximal biceps tendon pathology

The long head of the biceps tendon is widely recognized as an important pain generator, especially in anterior shoulder pain and dysfunction with athletes and working individuals. The purpose of this review is to provide a current understanding of the long head of the biceps tendon anatomy and its surrounding structures, function, and relevant clinical information such as evaluation, treatment options, and complications in hopes of helping orthopaedic surgeons counsel their patients. An understanding of the long head of the biceps tendon anatomy and its surrounding structures is helpful to determine normal function as well as pathologic injuries that stem proximally. The biceps-labral complex has been identified and broken down into different regions that can further enhance a physician’s knowledge of common anterior shoulder pain etiologies. Although various physical examination maneuvers exist meant to localize the anterior shoulder pain, the lack of specificity requires orthopaedic surgeons to rely on patient history, advanced imaging, and diagnostic injections in order to determine the patient’s next steps. Nonsurgical treatment options such as anti-inflammatory medications, physical therapy, and ultrasound-guided corticosteroid injections should be utilized before entertaining surgical treatment options. If surgery is needed, the three options include biceps tenotomy, biceps tenodesis, or superior labrum anterior to posterior repair. Specifically for biceps tenodesis, recent studies have analyzed open vs arthroscopic techniques, the ideal location of tenodesis with intra-articular, suprapectoral, subpectoral, extra-articular top of groove, and extra-articular bottom of groove approaches, and the best method of fixation using interference screws, suture anchors, or cortical buttons. Orthopaedic surgeons should be aware of the complications of each procedure and respond accordingly for each patient. Once treated, patients often have good to excellent clinical outcomes and low rates of complications.

Biceps tenotomy or tenodesis in association with rotator cuff repair: is there an influence on functional results? A retrospective cohort study

BACKGROUND

Instability or tears of the long head of the biceps tendon (LHBT) may be present in more than 35% of rotator cuff repairs (RCR).

OBJECTIVE

To compare clinical results from patients undergoing arthroscopic RCR, according to the procedure performed at the LHBT.

DESIGN AND SETTING

Retrospective cohort study designed at the shoulder and elbow clinic of Instituto de Ortopedia e Traumatologia, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Brazil.

METHODS

Functional results among patients were compared using the American Shoulder and Elbow Surgeons (ASES) and University of California Los Angeles (UCLA) scales, according to the LHBT approach adopted: no procedure, tenotomy or tenodesis.

RESULTS

We evaluated 306 shoulders (289 patients): 133 underwent no procedure at the LHBT, 77 tenotomy and 96 tenodesis. The ASES scale at 24 months showed no difference (P = 0.566) between the groups without LHBT procedure (median 90.0; interquartile range, IQR 29), tenotomy (median 90.0; IQR 32.1) or tenodesis (median 94.4; IQR 22.7); nor did the UCLA scale (median 33; IQR 7 versus median 31; IQR 8 versus median 33; IQR 5, respectively, P = 0.054). The groups differed in the preoperative functional assessment according to the ASES and UCLA scale, such that the tenodesis group started from higher values. However, there was no difference in pre and postoperative scores between the groups.

CONCLUSION

Tenodesis or tenotomy of the LHBT, in the sample analyzed, did not influence the clinical results from RCR, as assessed using the ASES and UCLA scales.

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.

Concomitant Biceps Tenodesis Improves Outcomes for SLAP Repair: Minimum 2-Year Clinical Outcomes after SLAP II-IV Repair Versus Tenodesis Versus Both

Purpose

To investigate clinical outcomes, return to sport, and complication rate in patients with an isolated SLAP II-IV tear treated with biceps tenodesis (BT), SLAP-repair (SLAP-R), or both (SLAP-R+BT).

Methods

A retrospective analysis of prospectively collected data was performed in patients who underwent surgery between February 2006 and February 2018 for isolated SLAP II-IV lesions with either BT, SLAP-R, or SLAP-R+BT and had minimum 2-year follow-up. Patients were excluded if they were older than 45 years of age, had anterior shoulder instability, rotator cuff tears, glenohumeral osteoarthritis, or concomitant fractures about the shoulder. Clinical outcomes were assessed by the use of the American Shoulder and Elbow Society Score, Single Assessment Numerical Evaluation Score, Quick Disabilities of the Arm, and Shoulder and Hand Score, the General Health Short Form-12 Physical Component, and patient satisfaction.

Results

There were 38 shoulders in the isolated BT group with 1 (2.6%) shoulder requiring revision, 13 in the SLAP-R group with no patient requiring revision, and 21 in the SLAP-R+BT group with 2 (9.5%) shoulders requiring revision. Minimum 2-year follow-up was obtained in >85% of each group. Mean age at time of surgery was significantly different between the groups (36.5 years BT vs 27.7 years SLAP-R vs 36.5 years SLAP-R+BT; P = .003). While patient-reported outcomes improved significantly from pre- to postoperatively for the BT (P < .001) and SLAP-R+BT groups (P < .001), they did not significantly improve for the isolated SLAP-R group (P values ranging .635 to .123). The BT and SLAP-R+BT groups showed significant improvement in return to sport pre- to postoperatively whereas the SLAP-R group did not. The SLAP-R+BT group had the most patients reaching minimal clinical important difference, substantial clinical benefit, and patient acceptable symptom state American Shoulder and Elbow Society Score scores; however, this was not statistically significant.

Conclusions

SLAP II-IV lesions treated with BT or both SLAP-R+BT demonstrated improved outcomes compared with isolated SLAP-R at minimum 2-year follow-up. Concomitant biceps tenodesis should be considered when performing repair of SLAP II-IV tears.

Level of Evidence

III; Retrospective comparative study.

Shoulder Long Head Biceps Tendon Pathology Is Associated With Increasing Rotator Cuff Tear Size

Purpose

To evaluate the association between rotator cuff tear (RCT) size and long head biceps tendon (LHBT) pathology.

Methods

We retrospectively enrolled 202 consecutive patients (114 women and 88 men with mean age at surgery of 62.14 years [SD, 7.73]) who underwent arthroscopic rotator cuff repair for different sized full-thickness RCTs. LHBT pathology was evaluated considering the presence of inflammation, section alteration, loss of integrity, dislocation, dynamic instability, and absence. The site of LHBT pathology was evaluated considering 3 portions: (1) the insertional element; (2) the free intra-articular portion; (3) the part that enters the intertubercular groove. Statistics were evluated.

Results

The LHBT was absent in 22 cases (10.9%): 2, 4, 15, and 1 patients with small, large, massive, and subscapularis RCTs, respectively. A significant correlation was found between the prevalence of LHBT absence and massive RCTs (P < .001). In 53 patients (26%), there was a healthy LHBT; a healthy LHBT was present in 47%, 20% and 8% of small, large and massive RCTs, respectively. A significant correlation between LHBT inflammation, section alteration, loss of integrity, and RCT severity was found (P < .001, P < .001, and ). The insertional portion was the most involved (57% of cases); RCT severity was significantly associated with the number of involved portions (P < .001).

Conclusions

Shoulder LHBT pathology is associated with increasing rotator cuff tear size.

Clinical Relevance

Surgeons should be aware that biceps pathology is particularly prevalent in patients with larger RTCs.

Long Head of the Biceps Tendon Ruptures: Biomechanics, Clinical Ramifications, and Management

»

Pathology of the long head of the biceps tendon is a common source of shoulder pain and often occurs in combination with other shoulder disorders.

»

Nonsurgical management, including rest and activity modification, use of nonsteroidal anti-inflammatory drugs, physical therapy, and corticosteroid injections, is usually the first line of treatment.

»

Patients with symptoms that are refractory to nonsurgical management are indicated for biceps tenotomy or various tenodesis procedures.

»

Although several studies have reported a higher incidence of "Popeye" deformity, muscle cramping, and pain in the bicipital groove postoperatively with tenotomy compared with tenodesis, there are no substantial differences in functional scores or patient satisfaction between the 2 techniques.

»

To date, both tenotomy and tenodesis have been shown to be effective options in the management of long head of the biceps tendinopathy, and there are advantages to each procedure.

The effects of nonsteroidal anti-inflammatory medications after rotator cuff surgery: a randomized, double-blind, placebo-controlled trial

BACKGROUND

Nonsteroidal anti-inflammatory drugs (NSAIDs) are frequently used for postoperative pain management. However, animal studies have demonstrated negative effects of NSAIDs on bone and tendon healing after commonly performed procedures such as rotator cuff repair. The purpose of this study was to evaluate the effects of postoperative NSAID use on opioid use, pain control, and shoulder outcomes after arthroscopic rotator cuff repair.

METHODS

A randomized, double-blind, placebo-controlled trial of postoperative NSAID use was performed in patients undergoing primary arthroscopic rotator cuff surgery at a single institution. Patients were randomized to receive ibuprofen or placebo for 2 weeks postoperatively, in addition to opioid medication. They were instructed to keep a daily pain diary for the first week after surgery, which was returned at their first postoperative visit for analysis. Visual analog scale (VAS) pain scores, shoulder range of motion, and 12-item Short Form Survey, Disabilities of the Arm, Shoulder and Hand, and American Shoulder and Elbow Surgeons (ASES) scores were collected. Assessment of rotator cuff healing was performed using ultrasound at 1 year postoperatively.

RESULTS

A total of 50 patients in the placebo group and 51 patients in the ibuprofen group were included for analysis. There were no differences in age, race, sex, history of preoperative NSAID or opioid use, or operative findings between groups. The amount of mean total morphine milligram equivalents (MMEs) used in the first postoperative week was lower in the ibuprofen group than in the placebo group (168 MMEs vs. 211 MMEs, P = .04). Early VAS scores on postoperative days 3, 4, 5, and 6 were lower in the ibuprofen group, but there was no difference in mean VAS scores between groups by 6 weeks after surgery. At 6 months, mean forward flexion and the mean ASES score were higher in the ibuprofen group than in the placebo group: 162° vs. 153° (P = .03) and 86 vs. 78 (P = .02), respectively. There were no differences in shoulder motion or 12-item Short Form Survey, Disabilities of the Arm, Shoulder and Hand, or ASES scores at 1 year. At 1 year after surgery, 7 patients in the ibuprofen group had evidence of tendon retear diagnosed on ultrasound (5 partial and 2 full thickness) compared with 13 patients in the placebo group (5 partial and 8 full thickness), but this difference was not statistically significant (P = .20).

CONCLUSION

Postoperative ibuprofen use reduces opioid requirements and decreases patient pain levels in the first week after arthroscopic rotator cuff repair. In addition, ibuprofen use after rotator cuff repair does not lead to an increased risk of tendon retear.

Expression of Substance P and Nerve Growth Factor in Degenerative Long Head of Biceps Tendon in Patients with Painful Rotator Cuff Tear

Purpose

Degenerative long head of biceps tendon (LHBT) has been recognized as a notable pain source in patients with rotator cuff tear (RCT). Tenotomy or tenodesis of LHBT is frequently indicated together with arthroscopic rotator cuff repair (ARCR) aiming for complete pain relief; however, it has not been fully investigated whether resected LHBT is really a source of pain. The purpose of this study was to investigate expression levels of pain-associated mediators in LHBT and its association with preoperative pain profiles.

Methods

Twenty-seven RCT patients who underwent ARCR with LHBT resection were included. Each LHBT was resected due to its abnormal arthroscopic findings including tenosynovitis, hypertrophy, and partial tear. Worst macroscopic lesion of the LHBT was obtained, and expression levels of substance P (SP) and nerve growth factor (NGF) were evaluated using enzyme-linked immunosorbent assay (ELISA). Ten healthy knee flexor tendons were analyzed as non-degenerative samples. Preoperatively, subjective shoulder pain VAS and pain duration were investigated. Conventional LHBT pain provocation tests (Speed, Yergason, O’Brien) were performed. Pressure pain threshold (PPT) of bilateral LHBT on the groove was recorded.

Results

Levels of SP and NGF expression were significantly higher compared with non-degenerative tendons (P<0.01). Shoulder pain VAS and pain duration were not directly associated with SP and NGF expression level. Patients with positive O’Brien test expressed greater SP than negative patients (P=0.001). Significant negative correlation between the PPT ratio (ipsilateral/contralateral) and SP expression level was observed (r=−0.453, P=0.034).

Conclusion

Greater expression of SP and NGF in degenerative LHBT supported our hypothesis that it would be a pain source in RCT patients. SP was likely to be expressed highly in patients with localized pressure pain hypersensitivity and positive O’Brien test (ie, altered mechanistic pain profile of LHBT), which may help when considering simultaneous LHBT resection during ARCR.

Clinical Registration

UMIN000023943.

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

Background

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

Methods

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

Results

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

Conclusions

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

Supplementary Information

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

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

ADVANCES IN KNOWLEDGE

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

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

Background/aim

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

Materials and methods

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

Results

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

Conclusion

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

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

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

III, prospective cohort study, diagnosis.

Measurement of biceps tendon retraction after arthroscopic tenotomy

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

IMPORTANCE

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

OBJECTIVE

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

EVIDENCE REVIEW

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

FINDINGS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

III.

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

Hypothesis/Background

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

Methods

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

Results

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

Discussion/Conclusion

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

Systematic review.

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

HYPOTHESIS

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

I; diagnostic study.

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

Descriptive laboratory study.

METHODS

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

RESULTS

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

CONCLUSION

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

CLINICAL RELEVANCE

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

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

Background:

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

Purpose:

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

Study Design:

Cross-sectional study.

Methods:

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

Results:

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

Conclusion:

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