Ultrasound evaluation of the distal migration of the long head of biceps tendon following tenotomy in patients undergoing arthroscopic repair of tears of the rotator cuff

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level-III evidence.

TYPE OF STUDY

Retrospective comparative study.

Distal Pullout Strengths of the Biceps Long Head Tendon for Different Adjacent Tissue and Tendon Pathologies during Rotator Cuff Repair

Purpose. Pathologies of the long head of the biceps tendon (LHBT) are frequently recognized in cases of rotator cuff tear. Recommendations for managing such pathologies remain debatable, and distal migration of tenotomized biceps is always a concern when only tenotomy is performed. Methods. Seventy patients of mean age 60.4 ± 6.9 years (range: 44 to 82 years) were included in this retrospective study. During subpectoral tenodesis in rotator cuff repair, pullout tensions were measured using a digital tensiometer. Measured tensions obtained were analyzed with respect to sex, tear involvement of the subscapularis, and the presence of a partial tear of LHBT, type II SLAP lesion, subluxation/dislocation of the biceps, or a pulley lesion. Results. Mean LHBT pullout tension for the 70 study subjects was 86.5 ± 42.1 N (26.7-240.5 N). Distal LHBT pullout tension was significantly greater for men than women (93.2 ± 42.7 N versus 73.7 ± 38.7 N, P = 0.041). However, LHBT pullout tensions were not significantly associated with different pathologies of surrounding tissues or of LHBTs (all Ps > 0.05). Conclusion. The study failed to show pullout tension differences associated with pathologies affect distal migration of a tenotomized LHBT. Gender was the only factor found to affect LHBT pullout strength. Risk of distal migration of tenotomized LHBT could not be predicted with intraoperative arthroscopic pathologic findings.

Biomechanical properties of tenotomy versus biceps knot in a cadaver model

BACKGROUND

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

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

Feasibility of ultrasound-guided percutaneous tenotomy of the long head of the biceps tendon--A pilot cadaveric study

OBJECTIVE

To describe an ultrasound-guided proximal percutaneous tenotomy technique of long head of the biceps tendon (LHBT).

METHODS

Three fresh cadavers with no prior shoulder surgery or LHBT tears were included in the study. A single experienced musculoskeletal radiologist completed six ultrasound-guided proximal percutaneous tenotomies of LHBT. A superficial to deep approach was performed on four shoulders using an arthroscopic banana blade or retractable blade. A deep to superficial approach was performed on two shoulders using an arthroscopic hook blade. A blinded anatomist dissected each specimen and graded the tenotomy, length of proximal LHBT stump, and evidence of iatrogenic injuries.

RESULTS

Four of the six cadaveric LHBTs were fully transected. The two partially transected tenotomies were performed using the arthroscopic banana and retractable serrated blades (63% and 80% transections, respectively). The proximal LHBT stump mean length was 2.6 cm (95% CI, 1.8-3.4). There was no evidence of iatrogenic lesions.

CONCLUSIONS

This cadaveric study showed that the ultrasound-guided percutaneous tenotomy of the LHBT is a feasible procedure. The deep to superficial approach using an arthroscopic hook blade resulted in complete transection. Further cadaveric studies with larger numbers are warranted to confirm this novel technique's applicability in clinical practice.

Biceps muscle fatty infiltration and atrophy. A midterm review after arthroscopic tenotomy of the long head of the biceps

PURPOSE

Pathology of the long head of the biceps (LHB) tendon is commonly treated by tenotomy. High levels of clinical function and patient satisfaction are reported in the short-term. The purpose of this study was to investigate the midterm effects of tenotomy on biceps fatty infiltration and atrophy in active working-age male patients.

METHODS

Twenty-five men (mean age, 57 years) were evaluated at a mean follow-up of 6.7 years after tenotomy. Bilateral magnetic resonance imaging (MRI) was performed, and fatty infiltration of the biceps was assessed relative to the ipsilateral triceps. Seventeen participants had an intact contralateral LHB tendon. To assess atrophy, anterior muscle compartment volume was measured by serial cross-sectional area measurements on MRI. The tenotomized side was then compared to the healthy side in these 17 participants. Clinical scores were obtained using the QuickDASH and Oxford Elbow Score, and the occurrence of a Popeye sign and residual pain were recorded.

RESULTS

Good clinical function was maintained at a mean follow-up time of 6.7 years (range, 4 to 10 years) (QuickDASH score of 7.1; standard error [SE], 1.8) and Oxford Elbow Score of 97.9 [SE 1.2]). Eleven of the 25 participants had a Popeye deformity. Four participants showed signs of fatty infiltration, and all were minor (grade 1). The mean decrease in total volume of the anterior musculature was 3.6%. In participants without a Popeye deformity, it was 3.3%, whereas it was 4.1% in participants with a Popeye sign (P = .8).

CONCLUSIONS

In the midterm, LHB tenotomy in active men of working age does not result in fatty degeneration or substantial atrophy in the anterior musculature of the arm. Clinical function remains good.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.