Biceps Tenodesis Research Articles

Concomitant Procedures, Black Race, Male Sex, and General Anesthesia Show Fair Predictive Value for Prolonged Rotator Cuff Repair Operative Time: Analysis of the National Quality Improvement Program Database Using Machine Learning

PurposeThe purpose of this study is to develop machine learning models using the American College of Surgeons National Quality Improvement Program (ACS-NSQIP) database to predict prolonged operative time (POT) for rotator cuff repair (RCR). Furthermore, this study aims to use the trained machine learning (ML) models, cross-referenced with traditional multivariate logistic regression (MLR), to determine the key perioperative variables that may predict POT for RCR. MethodsData were obtained from a large, national database (NSQIP) from 2021. Patients with unilateral RCR procedures were included. Demographic, preoperative, and operative variables were analyzed. A multivariable logistic regression (MLR) model and various other machine learning techniques, including random forest (RF) and artificial neural network (ANN), were compared using area under the curve (AUC), calibration, Brier score, and decision curve analysis. Feature importance was identified from the overall best-performing model. ResultsA total of 6,690 patients met inclusion criteria. The random forest (RF) ML model had the highest AUC upon internal validation (0.706) and the lowest Brier score (0.15), outperforming the other models. The RF model also demonstrated strong performance upon assessment of the calibration curves (Slope = 0.86, Intercept = 0.08) and decision curve analysis. The model identified concomitant procedure, specifically labral repair and biceps tenodesis, as the most important variable for determining POT, followed by age <30 years, Black or African American race, male sex, and general anesthesia. ConclusionsDespite the advanced machine learning models used in this study, the NSQIP dataset was only able to fairly predict POT following RCR. The RF model identified concomitant procedures, specifically labral repair and biceps tenodesis, as the most important variables for determining POT. Additionally, demographic factors such as age <30 years, Black race, and general anesthesia were significant predictors. While male sex was identified as important in the RF model, the MLR model indicated that its predictive value is primarily in conjunction with specific procedures like biceps tenodesis and subacromial decompression.

Poster 147: Patient-Reported and Clinical Outcomes up to 2 Years after Primary Rotator Cuff Repair: Do We Need a 2-Year Follow-Up Visit?

Objectives: Rotator cuff tears (RCTs) are the number one cause of shoulder pain and are becoming increasingly common as the population ages. The increasing incidence of RCTs present a significant economic burden, with shoulder pain being the No. 1 cause of disability in the United States. Repair of RCTs, in return, result in a cumulative $3.4 billion savings annually in the United States. Historically, follow-up for rotator cuff repair (RCR) mirrors that of hip and knee arthroplasty, with minimum of 2-year outcomes reported in most peer-reviewed studies. Recent literature, however, demonstrates no significant increase in clinically significant improvement after 6 months regarding functional outcomes and patient-reported outcomes (PROs) such as American Shoulder and Elbow Surgeons Shoulder Score (ASES), visual analog scale (VAS), and Disabilities of the Arm, Shoulder, and Hand (DASH) scores among others. The purpose of this study is to demonstrate degradation of outcome improvement in patient-reported outcomes after 1-year follow-up of RCR. We hypothesize that there will be no clinically significant increase in Single Assessment Numeric Evaluation (SANE) scores after 1 year postoperatively. The primary outcome of interest is change in SANE score over the 2-year episode of care. Methods: All patients that underwent primary RCR within a single health care system were eligible for inclusion in this study. Exclusion criteria included history of surgery on the affected shoulder, incomplete PROs at baseline, 1 year, or 2 years postoperatively, and concomitant fractures about the affected shoulder. Patient demographics, injury characteristics, and operative technical characteristics were obtained through review of the patients’ electronic medical records and operative reports. PROs included SANE, ASES, and VAS scores and were collected prospectively, then stored in a HIPAA-compliant database until reviewed retrospectively for this study. An anchor-based minimum clinically important difference (MCID) was calculated for the study cohort at 1 and 2 years postoperatively and was anchored on a 1-point increase in the Patient-Reported Outcomes Measurement Information System global 10 quality of life question. The primary outcomes of interest are baseline (preoperative), 1-year, and 2-year SANE scores. Secondary outcomes of interest included rates of symptomatic retear, reoperation, and revision. Statistical analysis was performed with a statistical analysis software (Intellectus). Analyses included descriptive statistics, t tests, chi-square tests of independence, Fischer exact tests, and analyses of variance, as appropriate. Statistical significance was defined as an alpha value of p ≤ 0.05. Results: A total of 495 patients met criteria for inclusion in the study (Table 1). The average age of the study population was 61.5 ± 8.4 years old, and the average body mass index (BMI) was 29.9 ±5.5. Most patients were men (287, 58.0%). A total of 24 patients were under workers’ compensation. Other medical comorbidities of interest included diabetes (74, 15.0%), depression (85, 17.2%), anxiety (74, 15.0%), and rheumatoid arthritis (6, 1.2%). Just over half of patients had chronic tears as described by the surgeon in clinical notes or operative reports (259, 52.3%), and most patients had full-thickness tears documented in the operative report (402, 81.2%). The most common adjuvant procedures included subacromial decompression (SAD) (419, 84.6%), biceps tenodesis (211, 42.6%) and distal clavicle excision (DCE) (133, 26.9%). Baseline SANE scores for the study cohort averaged 40.8 ± 20.3 with a subsequent of 43.4 within the first year postoperatively, bringing the 1-year SANE average to 84.1 ± 196 (p &lt; 0.001). After the 1-year follow-up, however, there was small but statistically significant change in SANE scores with the 2-year SANE scores averaging 87.5 ± 18.1, p &lt; 0.001) (Figure 1). One-year anchor-based MCID for SANE was found to be 45.5, with 238 (48.1%) meeting this MCID. At 2-years, 213 patients (43.0%) met the MCID of 50.6. Conclusions: Over the 2-year episode of care following primary RCR, patients saw an overall increase in SANE of 46.8. Even after the 1-year follow-up, patients continued to see statistically significant increases in SANE scores; however, they did not see clinically significant increase in PROs, as demonstrated by fewer patients meeting the 2-year MCID compared with the 1-year MCID. [Figure: see text]

Poster 108: Arthroscopic Posterior Labral Repair Patients Experience Less Instability Events and Full Dislocations Yet Are More Commonly Male Contact Athletes that Require Concomitant Procedures When Compared to Arthroscopic Anterior Labral Repair Patients

Objectives: Direct comparisons between the direction of shoulder instability as it pertains to clinical and demographic risk factors are lacking. The purpose of this study is to identify and compare demographic, clinical, and peri-operative variables in patients receiving arthroscopic treatment for anterior and posterior shoulder instability. Methods: A retrospective chart review was performed for consecutive patients who underwent primary arthroscopic labral repair surgery for anterior and posterior shoulder instability with a minimum 2-year follow-up. Surgeries were performed by six surgeons at a single institution between 2012-2020. Patients with prior shoulder instability surgeries of any kind were excluded. Demographics and operative variables included sex, body mass index (BMI), Contact/collision sports, tobacco use, ASA grade, number of dislocations (&lt;1, 1, 2, &gt;2), tear size (120, 240, and 360 degrees), age, time from first dislocation to surgery, number of anchors, and concomitant procedures. Study groups were compared using student’s t-tests and Mann-Whitney U test for continuous variables and Chi-Square or Fisher’s Exact tests for discrete variables with a significance of 0.05. Results: Five hundred and twenty-four (524) patients met inclusion criteria. Overall, there were 133 females (25.4%) and 291 males (74.6%) with a mean age of 27.1 years at the time of surgery (SD ± 9.9) and a BMI of 26.6 (SD ± 5.6). Posterior instability patients were less likely to have experienced a dislocation (15.1% without prior dislocation) than patients with anterior instability (3.4%). Additionally, posterior instability patients that did experience a dislocation (22.6%) were less likely to have greater than two dislocations when compared to anterior instability patients (53.6%). Posterior instability was more frequently associated with males (85%), higher BMI (mean = 28.25), and contact/collision sports (41%). Posterior instability patients were more likely than anterior instability patients to have concomitant procedures performed at the time of labral repair, including capsular plication, (31.6%) biceps tenodesis (14%), and distal clavicle excision (8.8%). Lastly, posterior instability patients typically required fewer anchors (3.4) than anterior instability patients (3.98) at the time of labral repair. Conclusions: Despite having fewer instability events or dislocations, patients that receive a posterior labral repair are more likely to have additional injuries in their shoulder requiring treatment when compared to patients that have received an arthroscopic anterior labral repair. Interestingly, posterior labral repair patients are more commonly male, and contact athletes, as well. With posterior shoulder instability being less common, we speculate that these findings could correlate with a more significant amount of energy/mechanism involved when a shoulder does dislocate posteriorly, thus leading to injuries to additional shoulder structures. It also correlates with the repetitive microtrauma mechanism that can happen with posterior labral tears. Whereas patients may be more likely to experience symptoms over a longer period of time without ever having a full instability event and additional shoulder structures become injured.

Poster 131: Loop 'N' Tack Tenodesis: A Multi-Center Retrospective Case Series of Clinical and Patient Reported Outcomes of a Novel Suture Technique for Proximal Biceps Tenodesis

Objectives: Tenodesis and tenotomy of the long head of the biceps are treatment options for a wide range of pathologies without clear superior technique or site of fixation. Tenotomy may result in a cosmetic “Popeye” deformity and fatigue pain. The Loop ‘N’ Tack technique is a quick, simple, and knotless technique for tenodesis of the long head of the biceps that can be completed entirely arthroscopically. The tensionless repair allows the biceps to scar within the biceps groove, thereby reducing subsidence and formation of a “Popeye" deformity and fatigue pain in the biceps seen with tenotomy alone while eliminating the ability to overtension. The primary objective will be to retrospectively report the clinical outcomes and associated complications of patients undergoing biceps tenodesis utilizing the Loop ‘N’ Tack technique at multiple institutions from 1/1/2015 – 7/25/2021. Methods: CPT procedure codes (29827,29823, 29826) were used to identify participants in the EHR (i.e., Epic) who underwent the Loop ‘N’ Tack biceps tenodesis technique by each author at 9 separate institutions. Patient reported outcomes (PRO) including Visual Analog Scale (VAS), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Single Assessment Numeric Evaluation (SANE), UCLA Shoulder Rating Scale (UCLA), and Simple Shoulder Test (SST) were recorded at multiple time points throughout the patient’s preoperative and postoperative course. Scores were compared to the established minimal clinically important difference (MCID) for each PRO to assess the viability of this tenodesis technique. Additional metrics including bicipital groove pain, Popeye deformity, and need for revision surgery were also recorded. Results: 1,473 patients were initially screened who underwent the Loop ‘N’ Tack biceps tenodesis technique. 82 patients were excluded secondary to limited follow up or lack of PRO data within the EHR. The average patient age was 64.7 years old with average follow up of 8.11 months. Mean preoperative PRO scores were 5.64 (2.13), 43.31 (20.38), 15.14 (3.52), 5.81 (1.92), and 49.24 (15.06) for the VAS, SANE, UCLA, SST, and ASES scores, respectively. Postoperative PRO scores at most recent follow up respectively measured 1.05 (1.66), 89.56 (17.06), 31.50 (4.01), 10.69 (1.92), and 89.48 (13.81). MCID was reached for each PRO at the 1-2 month mark postoperatively. 36 patients (2.6%) underwent revision surgery for biceps related pathology, while 40 patients (2.9%) required revision shoulder surgery for a separate pathology. Postoperative Popeye deformity was noted in 15 patients (1.08%). Conclusions: The Loop ‘N’ Tack technique results in high rates of patient satisfaction with improvement in shoulder related patient reported outcomes, low incidence of postoperative pain, and low rates of Popeye deformity. This case series establishes the Loop ‘N’ Tack technique as a viable tenodesis approach during shoulder arthroscopy for biceps related pathology.

All Suture Biceps Tenodesis Has Greater Biomechanical Strength Than Metal Button Fixation

All Suture Biceps Tenodesis Has Greater Biomechanical Strength Than Metal Button Fixation

All-Suture Anchor Techniques for Biceps Tenodesis Are Noninferior in End-Cycle Stiffness to an Interference Screw Technique; However, Secondary Outcomes, Such as Ultimate Failure Load, Yield Load, Creep, and Load-to-Failure Stiffness, Are Inferior in an Ovine Model

PurposeThe purpose of this study was to assess the biomechanical performance of two simplified loop and tack biceps tenodesis techniques, all-suture anchor and all-suture anchor with a button, compared to the interference screw technique in an ovine model. MethodsTwenty-one biceps tenodesis procedures were executed on the humeri and flexor digitorum profundus tendons of skeletally mature, female sheep. Limbs were evenly randomized into two experimental groups (all-suture anchor with/without button) and one control group (interference screw). Cyclic loading followed by a load-to-failure test was conducted.The primary outcome metric was end-cycle stiffness, or stiffness measured at the end of cyclic loading, as it modeled the resistance of the construct to the lower-force activities of postoperative physical therapy. Secondary metrics included ultimate failure load (UFL), yield load, creep, and load-to-failure stiffness. End-cycle stiffness difference-of-means testing was conducted with a minimal clinically significant difference (MCID) threshold of -15N/mm (1.5kg/mm). Groups were compared using ANOVA for all recorded variables. ResultsBoth the all-suture anchor and all-suture anchor with button techniques were found to be noninferior in end-cycle stiffness compared to the interference screw technique (-5.2N/mm, 95% CI [-13.6, 3.3] and –3.8N/mm, 95% CI [-12.5, -4.9]) for -15N/mm MCID. The all-suture techniques showed significantly lower UFL, lower yield load, greater creep, and lower load-to-failure stiffness (P<0.001, P<0.001, P=0.002, P<0.001, respectively). Tendon dimensions did not vary significantly across groups. ConclusionsUnder subfailure loading conditions, the all-suture anchor with/without button techniques demonstrated end-cycle stiffness noninferiority with an interference screw technique, however, these techniques were inferior in all secondary outcomes, including significantly lower UFL, lower yield load, greater creep, and lower load-to-failure stiffness. Clinical RelevanceThe all-suture anchor with/without button approaches may retain the natural length-tension dynamics of the long head biceps tendon as fixation can occur before releasing the tendon origin. Additionally, it may offer a simpler and more cost-effective alternative to prevailing arthroscopic methods.

Histological features of the structure of the long head of biceps brachii tendon in patients with concomitant injuries of the rotator cuff

Background. The long head of biceps brachii tendon plays an important role in shoulder pain. Surgical tactics remain controversial. There are two approaches: tenotomy of the long head of biceps brachii tendon and tenodesis. Both have positive and negative sides. There is also no consensus on the effective position for performing tenodesis.The aim. To assess the histological structure of various parts of the long head of biceps brachii tendon, which may be the causes for persistent pain syndrome.Materials and methods. In this study, we examined the histological structure of the long head of biceps brachii tendon in 12 patients aged 18–59 years having chronic anterior shoulder pain with concomitant damage to the supraspinatus and subscapularis tendons. In all cases, magnetic resonance imaging (MRI) revealed changes that made it impossible to perform intraarticular tenodesis. Patients were divided into two groups according to the World Health Organization classification: young (18–44 years) and middle-aged (45–59 years). All patients underwent arthroscopy with subpectoral tenodesis and correction of concomitant pathology. The obtained macropreparations are divided into three zones: the proximal zone, the intertubercular zone and the zone below the intertubercular groove. All macropreparations were sent for histological examination.It was revealed that the most common changes occur in the area of the intertubercular groove in all categories, however, in the middle-aged group, the signs of inflammation and degeneration are equally evident in this zone and in the proximal part of the tendon.Conclusions. Young and middle-aged patients with damage to the tendons of the supraspinatus and subscapularis muscles and signs of chronic tendinitis of the long head of biceps brachii tendon tendon and pronounced structural changes according to MRI should undergo a subpectoral tenodesis procedure; it is also necessary to take into account the anatomical features of the tendon and possible surgical risks.

Improved Clinical Outcomes After Partial Repair and In Situ Biceps Tenodesis for the Treatment of Massive Irreparable Rotator Cuff Tears

To present the short-term outcomes of arthroscopic in situ biceps tenodesis combined with partial rotator cuff repair in patients with massive irreparable rotator cuff tears (MIRCTs) and minimal arthritis. A retrospective review was conducted using prospectively maintained institutional databases to identify patients who had undergone a partial rotator cuff repair with in situ biceps tenodesis between March 2017 and December 2022. Patients were included if they (1) were diagnosed pre- or intraoperatively with MIRCT and (2) had complete preoperative and minimum 1-year postoperative patient-reported outcome measures. Thirty-nine patients met the eligibility criteria and were included for analysis. The mean age of the study participants was 65 ± 7 years (range, 46-76) with 76.9% (n= 30) being male. The average follow-up was 21 ± 12 months (range, 12-58). Patients experienced significant improvement in visual analog scale for pain (VAS), American Shoulder and Elbow Surgeons (ASES) score, and subjective assessment numeric evaluation (SANE) score (P < .001 for all comparisons). The pre- to postoperative improvement was 3.1 ± 2.3 for VAS, 27.5 ± 20.6 for ASES, and 31.3 ± 24.8 for SANE. Postoperatively, the average scores for VAS, ASES, and SANE were 1.3 ± 1.5, 79.5 ± 17.0, and 69.6 ± 20.1, respectively. Twenty-six patients (66.7%) achieved the minimal clinically important difference (MCID) for VAS, 33 patients (84.6%) achieved the MCID for ASES, and 30 patients (76.9%) achieved the MCID for SANE. Partial rotator cuff repair with in situ biceps tenodesis is an effective treatment for MIRCT, leading to significant improvements in patient-reported outcome and range-of-motion measures compared to preoperative conditions. Level IV, retrospective case series.

All-suture anchor size and drill angle influence load to failure in a porcine model of subpectoral biceps tenodesis, a biomechanical study

BackgroundTenodesis of the long head of the biceps tendon is frequently performed in shoulder surgery, and all-suture anchors have become more popular as fixation methods. However, uncertainty still exists regarding the ultimate load to failure of all-suture anchors and the best insertion angle at a cortical humeral insertion point.PurposeThe purpose of this study was to compare the biomechanical characteristics of three types of all-suture anchors frequently used for biceps tenodesis. In addition, the influence of two different insertion angles was observed in a porcine humeri model.MethodsThe ultimate load to failure and failure mode of three types of all-suture anchors (1.6 FiberTak®, 1.9 FiberTak®, 2.6 FiberTak®, Arthrex®) applicable for subpectoral biceps tenodesis were evaluated at 90° and 45° insertion angles in 12 fresh-frozen porcine humeri. The anchors were inserted equally alternated in a randomized manner at three different insertion sites along the bicipital groove, and the suture tapes were knotted around a rod for pullout testing. In total, 36 anchors were evaluated in a universal testing machine (Zwick & Roell).ResultsThe 2.6 FiberTak® shows higher ultimate loads to failure with a 90° insertion angle (944.0 N ± 169.7 N; 537.0 N ± 308.8 N) compared to the 1.9 FiberTak® (677.8 N ± 57.7 N; 426.3 N ± 167.0 N, p-value: 0.0080) and 1.6 FiberTak® (733.0 N ± 67.6 N; 450.0 N ± 155.8 N, p-value: 0.0018). All anchor types show significantly higher ultimate loads to failure and smaller standard deviations at the 90° insertion angle than at the 45° insertion angle. The major failure mode was anchor pullout. Only the 2.6 FiberTak® anchors showed suture breakage as the major failure mode when placed with a 90° insertion angle.ConclusionsAll three all-suture anchors are suitable fixation methods for subpectoral biceps tenodesis. Regarding our data, we recommend 90° as the optimum insertion angle.Clinical relevanceThe influence of anchor size and insertion angle of an all-suture anchor should be known by the surgeon for optimizing ultimate loads to failure and for achieving a secure fixation.

Arthroscopic Biceps Tenodesis With Interference Screw Fixation: A Technique Video

Background: Management of long head of the biceps tendon (LHBT) pathology is accomplished through a biceps tenotomy or tenodesis. While both modalities provide beneficial outcomes, a biceps tenodesis may confer improved cosmesis, functional outcomes, and decreased muscle cramping postoperatively. Many procedural considerations are undertaken prior to a tenodesis, such as the surgical approach and fixation device. While similar clinical outcomes are achieved between an open subpectoral and arthroscopic suprapectoral biceps tenodesis (ASPBT) with interference screw (IS) fixation, the latter technique offers a minimally invasive modality. Indications: The primary indications for an ASPBT include superior labrum anterior posterior (SLAP) tears, LHBT tears, biceps instability, bicipital tunnel disease, biceps pulley lesions, and biceps tenosynovitis. Contraindications to the arthroscopic approach include a distal lesion of the biceps tendon below the pectoralis major tendon (PMT). The IS may be used to create a biomechanically stiffer construct. Technique Description: With the arthroscope in the lateral portal, the distal aspect of the bicipital groove proximal to the superior border of the PMT is identified and opened. The LHBT is subsequently mobilized and released. An anterosuperolateral portal is localized with a spinal needle positioned perpendicular to the bicipital tunnel, 1.5 cm proximal to the superior border of the PMT. The biceps is then removed ex vivo and whip-stitches are sewn beginning 1 cm proximal to the myotendinous junction of the LHBT. After firmly associating the LHBT with the tip of the IS, a guidewire is placed 1.5 cm superior to the superior border of the PMT, perpendicular to the humerus, and a reamer is used to prepare a 6-, 7-, or 8-mm diameter socket. The tendon is inserted through the accessory portal into the tunnel, followed by screw fixation. Suture tails are tied with 5 alternating half hitches, each secured via an arthroscopic knot pusher. Results: ASPBT with IS fixation provides significant pain relief, improves range of motion (ROM), and enhances quality of life. Discussion: ASPBT with IS fixation provides significant improvements in patient-reported and functional outcomes and thus can be an acceptable treatment for LHBT pathology. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Biomechanical comparisons of all--suture suspensory button vs. interference screw for inlay subpectoral bicep tenodesis

All-suture buttons (ASBs) and interference screw (IS) are commonly utilized in the inlay subpectoral biceps tendon tenodesis. However, the biomechanical characteristics of these two methods have not been compared directly. The aim of present study was to compare the biomechanical properties of ASB vs. IS for inlay subpectoral biceps tendon tenodesis in a human cadaveric model. Sixteen fresh-frozen human cadaveric shoulders were randomly divided into two experimental inlay biceps tenodesis groups: ASB or IS. After tenodesis, every specimen was preloaded at 5N for 2minutes, followed with a cyclic loading test from 5 to 70N for 500 load cycles. Then the load-to-failure test was performed. Afterward, the humerus was placed in a cylinder tube and secured with anchoring cement. Lastly, a two-point bending test was performed to determine the strength of the humerus. Destructive axial force was applied, and the failure strength and displacement were recorded. No difference in stiffness was observed between the two groups (ASB=27.4±3.5N/mm vs. IS=29.7±3.0N/mm; P=.270). Cyclic displacement was significantly greater in the ASB group (6.8±2.6mm) than the IS group (3.8±1.1mm; P=.021). In terms of failure load, there were no statistical differences among the two groups (P=.234). The ASB group was able to withstand significantly greater displacement (11.9±1.6mm) before failure than the IS group (7.8±1.5mm; P=.001). During the humeral bending test, the ASB group exhibited significantly greater maximal load (2354.8±285.1N vs. 2086.4±296.1N; P=.046) and larger displacement (17.8±2.8mm vs. 14.1±2.8mm; P=.027) before fracture. In inlay subpectoral bicep tenodesis, ASB fixation appears to offer comparable stiffness and failure load to that of IS fixation. Additionally, the ASB group exhibited greater resistance to load and displacement before humeral fracture. However, the ASB group did demonstrate increased cyclic displacement compared to IS group.

Descriptive Analysis of the Long Head of the Biceps Abnormalities in Distal Isolated Supraspinatus Tears Based on Video Records: A Study From the SFA Biceps Study Group Using the “Biceps Box” Concept

Background: Considering the long head of biceps (LHB) management, important cultural differences exist among the surgeons around the world, especially when repairing small isolated distal supraspinatus tears under arthroscopy. In the perspective of an international survey to analyze our practice regarding biceps management in small rotator cuff tears, the aim is to collect all the possible LHB abnormalities according to literature review, before considering that the LHB could be normal or pathologic. Indications: The SFA (Société Francophone d’Arthroscopie) behind its research biceps group summarized these abnormalities in a description analysis called the “biceps box” concept, which was validated with a strong inter-rater reliability. The aim is to present the description analysis using a common language with short video records for each abnormality described to reproduce “intraoperatively” the different possible scenarios the surgeon has to encounter during arthroscopic evaluation. Technique Description: The description of the “biceps box” concept classifies lesions of the LHB, with so-called intrinsic lesions, for which the LHB should be considered pathological: partial rupture or delamination, fissuring, lateral or medial instability or subluxation, hypertrophy with an hourglass figure; and so-called extrinsic lesions, for which the LHB should be considered healthy: damage to the pulley without bicipital instability, exposure of the articular portion of the biceps by rupture of the supraspinatus tendon, inflammation of the superficial surface of the tendon, presence of type 1 or 2 superior labral anterior to posterior (SLAP) lesions, or a chondral print. Results: We present the 10 possible scenarios with video records according to our description analysis. Discussion/Conclusion: The LHB could be considered as a pain generator in certain situations which are still not completely clear. The indication of biceps tenotomy or tenodesis depends on the interpretation of the surgeon of these abnormalities as a pathologic or a normal condition. The next step is to use these videos in an international survey to assess cultural differences regarding the management and eventually find a consensus regarding treatment options for each abnormality. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Arthroscopic Suprapectoral Biceps Tenodesis for Isolated Biceps Tendinopathy: Results From 23 Patients.

Pathology affecting the long head of the biceps tendon (LHB) is a common cause of shoulder pain. When conservative treatment fails to resolve symptoms, surgical treatment is the modality of choice. The literature describes many arthroscopic and open techniques using different implants. However, no consensus exists on which procedure yields the greatest improvement. The purpose of this study was to evaluate the effectiveness and safety of arthroscopic suprapectoral biceps tenodesis for treating isolated LHB pathology. We present a case series of 23 patients with isolated LHB pathology who were treated with arthroscopic suprapectoral tenodesis between 2016 and 2022. All surgeries were performed by the same senior surgeon, and patients were assessed preoperatively and one year after the procedure, using the simple shoulder test (SST), Constant score (CS), and visual analog scale (VAS) by the senior surgeon. Statistical analysis was performed using the Wilcoxon Signed Rank test, with significance defined as p < 0.05. The CS improved from 68.52 (SD = 1.59) to 98 (SD = 7.1; p < 0.001), the SST improved from 8.78 (SD = 0.998) to 11.21 (SD = 0.42; p < 0.001), and the VAS improved from 8.26 (SD = 0.54) to 0 (SD = 0; p < 0.001) at one-year follow-up. No complications were reported postoperatively or during the follow-up period. Arthroscopic suprapectoral biceps tenodesis significantly improved outcomes at one-year follow-up and can be considered an effective and safe choice when treating LHB pathology.

Biceps tenotomy vs. tenodesis: an ACS-NSQIP analysis of postoperative outcomes and utilization trends

BackgroundWhile studies have assessed comparative rates of restoration of shoulder function and alleviation of symptoms, comparative systemic postoperative complication rates between biceps tenotomy and tenodesis have yet to be assessed. The purpose of the present study was to use a national administrative database to perform a comprehensive investigation into 30-day complication rates after biceps tenotomy versus tenodesis, thus providing valuable insights for informed decision-making by clinicians and patients regarding the optimal surgical approach for pathologies of the long head of the biceps tendon. MethodsThe National Surgical Quality Improvement Program (NSQIP) database was queried to analyze postoperative complication rates and metrics associated with biceps tenotomy and tenodesis. Patient data spanning from 2012-2021 were extracted with relevant variables assessed to identify and compare these two surgical approaches. Adjusted and unadjusted analyses were utilized to analyze patient demographics, comorbidities, operative times, lengths of stay, readmissions, adverse events, and yearly surgical volume, along with trends in usage, across cohorts. ResultsOf 11,527 total patients, 264 (2.29%), 6,826 (59.22%), and 4,437 (38.49%) underwent tenotomy, tenodesis with open repair, and tenodesis with arthroscopic repair, respectively. Tenotomy operative times ([mean ± SD]: 66.25 ± 44.76 minutes) were shorter than those for open tenodesis (78.83 ± 41.82) and arthroscopic tenodesis (75.98 ± 40.16). Conversely, tenotomy patients had longer hospital (0.88 ± 4.86 days) relative to open tenodesis (.08 ± 1.55) and arthroscopic tenodesis (.12 ± 2.70). Multivariable logistic regression controlling for demographics and comorbidities demonstrated that patients undergoing tenodesis were less likely to be readmitted (adjusted odds ratio [AOR]: 0.42, 95% confidence interval [CI]: 0.17-0.98, P =0.050) or sustain serious adverse events (AOR: 0.27, 95% CI: 0.13-0.57, P <.001), but equally likely to sustain minor adverse events (AOR: 0.87, CI: 0.21-3.68, P =.850), compared with patients undergoing tenotomy. Lastly, comparing utilization rates from 2012 to 2021 revealed a significant decrease in the proportion of tenotomy (from 6.2% to 1.0%) compared to open tenodesis (from 41.0% to 57.3%) and arthroscopic tenodesis (52.8% to 41.64%; Ptrend = .001). ConclusionTo our knowledge, this is the first large national database study investigating postoperative complication rates between the various surgical treatments for pathologies of the long head of the biceps tendon. Our results suggest that tenodesis yields fewer serious adverse events and lower readmission rates than tenotomy. We also found a shorter operative time for tenotomy. These findings support the increased utilization of tenodesis relative to tenotomy in recent years.

Proximal humerus open reduction internal fixation with and without biceps tenodesis: assessment of early clinical outcomes

BackgroundThe role of biceps tenodesis (BT) during open reduction and internal fixation (ORIF) of proximal humerus fractures (PHF) remains unclear. A subset of patients undergoing ORIF have persistent pain with unclear etiology. The purpose of our study was to compare outcomes of ORIF of proximal humerus fractures with and without concomitant biceps tenodesis (BT). We hypothesize patients undergoing biceps tenodesis at the time of ORIF will have improved patient-reported outcome scores with fewer secondary procedures related to treatment of the biceps. MethodsIn this retrospective cohort study, all patients undergoing ORIF for a PHF at a single level one trauma center from January 2019 to June 2022 were reviewed. Patients under the age of 18 were excluded. Primary outcomes were PROMIS physical function, depression, and pain interference scores at 5 time points up to final follow-up. Secondary outcomes included total operative time, complications, subsequent procedures, steroid injections, and range of motion. Chi-square tests were performed for categorical values and paired t-tests for continuous variables. Results71 patients met inclusion criteria: 41 undergoing ORIF without BT, and 30 undergoing ORIF with BT. Average follow-up was 11 months. There were no statistically significant differences in patient demographics between groups. There were no differences in PROMIS scores at any time point postoperatively. At final follow-up patients in the ORIF with BT group had higher forward flexion than those who did not undergo BT (142 vs. 123 degrees, respectively, p < .02). There were no differences in surgical time, revision rates, postsurgical complications, or postoperative injections between groups. ConclusionBiceps tenodesis performed during ORIF of PHFs did not result in significantly different functional or patient-reported outcomes between groups, except for greater forward flexion at final follow-up. Although BT was done more commonly in severe PHFs, patients in both groups had similar rates of subsequent biceps-related procedures and revision surgery.

Investigation of the pressure value while performing biceps tenodesis for superior capsuler reconstruction

BackgroundTo compare the histopathological results of biceps tenodesis (BT) performed with normal, low, and high pressures for superior capsule reconstruction (SCR) in rabbits with massive rotator cuff tears.Materials and methodsThirty rabbits were divided into three groups. Rabbits 1–10 underwent SCR with BT at the same pressure (Group 1), value measured in the groove; 50% lower (Group 2); 50% higher (Group 3). After the 4-week follow-up, shoulder were en-bloc excised and histopathological evaluation was performed with modified Bonar’s scale. Results were compared between the groups, statistically.ResultsExtracellular matrix were significantly lower in group 2 compared to the other groups (p < 0.05). Cellularity levels were significantly lower in group 2 compared to the other groups (p < 0.05). Group 2 had no difference between the sides (p > 0.05). Group 2 had lower vascularity levels compared to the other groups (p = 0.01).DicsussionWhen the biceps tendon was in the bicipital groove and in a more mobile state with lower pressure exposure. BT performed with a tension that creates less pressure than the biceps in the groove is more successful in SCR.

Return to Sports and Clinical Results After All-Arthroscopic Biceps Tenodesis Using a 2.7-mm Knotless PEEK Suture Anchor.

The long head of the biceps tendon (LHBT) is a well-known source of pain in the shoulder, especially in active patients. To evaluate the outcomes and return-to-sports rate after all-arthroscopic suprapectoral tenodesis of the LHBT using a small knotless anchor. Case series; Level of evidence, 4. In this retrospective study, 27 patients-who underwent all-arthroscopic tenodesis of the LHBT using a 2.7-mm knotless polyether ether ketone anchor-were evaluated. Sports activities, the return-to-sports rate, and other sports-related parameters (eg, pain during sports, level of sports) were examined. Sports-related data, the Constant score with isometric force (at 90° of abduction in the scapular plane), the American Shoulder and Elbow Surgeons (ASES) score, the Simple Shoulder Test (SST) score, the visual analog scale (VAS) score for satisfaction, range of motion, and the presence of a Popeye deformity were assessed at a mean follow-up of 15.3 ± 8.7 months. The data were initially analyzed using descriptive statistics. The postoperative ASES, Constant, and SST scores were 81.61, 85.74 and 8.85, respectively. Of the 27 patients, 4 patients (14.8%) showed a Popeye deformity. Preoperatively, 25 patients (92.6%) participated regularly in some type of sports activity. All 25 patients (100.0%) were able to return to sports activities after surgery. 24 (96.0%) returned to the same level preoperatively, with 88.0% (22/25) within 6 months. Patient satisfaction with the outcome was high (VAS score: 2.15 ± 2.78). Neither bicipital groove pain nor cramping was reported. There were no signs of osteolytic bone around the anchor or a fracture of the humeral bone. Our clinical results after using a 2.7-mm knotless anchor for LHBT tenodesis as well as the return-to-sports rate were satisfying. Using an anchor this size can lower the risk of cortical bone damage and therefore the risk of fractures of the humeral head while still enabling patients to perform at a high level.

No clinical difference in outcomes between inlay and onlay arthroscopic biceps tenodesis techniques during rotator cuff repair

BackgroundBoth inlay and onlay arthroscopic biceps tenodesis (ABT) are common procedures performed during rotator cuff repair. The inlay method involves creating a bone socket in the bicipital groove to secure the long head of the biceps tendon (LHBT) using an interference screw. The onlay method utilizes a suture anchor to secure the LHBT on the surface of the bicipital groove. Little is known on the long-term differences in patient reported outcomes (PROs) between these two techniques. The primary purpose of this study was to compare PROs of inlay versus onlay ABT with a minimum follow-up of two years. Secondary aims were to evaluate the impact of rotator cuff tear size on outcomes and compare rates of complications between the two techniques. MethodsA retrospective chart review was performed to identify patients who had an ABT during a full-thickness rotator cuff repair. Any symptom specific to the biceps were noted, including pain and cramping, Popeye deformity, or revision surgery. Complication rates were compared between groups. The VAS pain score, ASES, SANE, and VR-12 scores were compared at two years. The impact of rotator cuff tear size was analyzed by categorizing into small/medium or large/massive based on operative reports and arthroscopic images. ResultsThere were 165 patients identified (106 in the inlay group and 59 in the onlay group). No revision surgeries were performed secondary to the biceps tendon in either group. Eleven patients (10%) in the inlay group complained of biceps pain or cramping compared to 2 patients (3%) in the onlay group (p = .11). One Popeye deformity was noted in each group (p = .67). No significant differences were found between groups for VAS (p=.41), ASES functional (p = .61), ASES Index (p = .91), SANE (p = .09), VR-12 PCS (p = .77), or VR-12 MCS (p = .09). Rotator cuff tear size within the groups also did not demonstrate statistical significance. ConclusionNo clinical differences or complications were found at minimum two-year follow-up between inlay and onlay arthroscopic biceps tenodesis in patients undergoing rotator cuff repair when controlling for tear size. The clinical relevance suggests either technique is effective and can be based on surgeon preference.

Open Biceps Tenodesis and Tenotomy Have Low 30-Day Postoperative Complication Rates

PurposeTo compare 30-day postoperative rates of adverse events, particularly infection rates, between open biceps tenodesis and biceps tenotomy. MethodsThe American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) was filtered using current procedural terminology (CPT) codes to identify patients undergoing open biceps tenodesis and tenotomy from 2010-2021. Patients were divided into cohorts based on procedure type. Propensity score matching was used to account for confounding variables. Statistical analyses were conducted to compare 30-day postoperative outcomes between cohorts, as well as to evaluate secondary risk factors for complications. ResultsOverall, 12,367 patients were included in the study with 11,417 undergoing open biceps tenodesis and 950 undergoing biceps tenotomy. After matching, 1,900 patients were included in the final analysis. The rate of outpatient procedures in the tenodesis cohort was significantly higher than in the tenotomy cohort. Rates of any adverse event (AAE), sepsis, pneumonia, reoperation, and extended length of stay (LOS) were significantly higher in the tenotomy cohort compared to the tenodesis cohort. There was no difference in infection rates or wound dehiscence between the two groups. After multivariable analysis, increasing age, longer operative time, and history of bleeding disorders were associated with significantly higher odds of developing any adverse event (AAE). ConclusionsIn this study we found that tenotomy and open tenodesis are both safe options for treatment of biceps pathology. The overall rate of developing any adverse event and the rate of postoperative sepsis were higher in the tenotomy cohort. In addition, rates of postoperative infection and wound dehiscence did not vary between the two groups. Small differences were additionally observed in rates of pneumonia, return to OR, and extended LOS, and these rates were higher in the tenotomy cohort. Level of EvidenceLevel III, retrospective comparative study.

What are the common factors that lead to the failure to achieve minimal clinically important difference after shoulder surgery? A scoping review.

The goal of this research is to identify the factors that negatively impact the achievement of the minimum clinically significant change (MCID) for the American Shoulder and Elbow Surgeons (ASES) score within the realm of various orthopedic shoulder procedures. We conducted a comprehensive review of studies published from 2002 to 2023, utilizing OvidMedline and PubMed databases. Our search criteria included terms such as "minimal clinically important difference" or "MCID" along with associated MeSH terms, in addition to "American shoulder and elbow surgeon" or "ASES." We selectively included primary investigations that assessed factors linked to the failure to achieve MCID for the ASES score subsequent to orthopedic shoulder procedures, while excluding papers addressing anatomical, surgical, or injury-related aspects. Our analysis identified 149 full-text articles, leading to the inclusion of 12 studies for detailed analysis. The selected studies investigated outcomes following various orthopedic shoulder procedures, encompassing biceps tenodesis, total shoulder arthroplasty, and rotator cuff repair. Notably, factors, such as gender, body mass index, diabetes, smoking habits, opioid usage, depression, anxiety, workers' compensation, occupational satisfaction, and the preoperative ASES score, were all associated with the inability to attain MCID. In summary, numerous factors exert a negative influence on the attainment of MCID following shoulder procedures, and these factors appear to be irrespective of the specific surgical technique employed. Patients presenting with these factors may perceive their surgical outcomes as less successful when compared to those without these factors. Identifying these factors can enable healthcare providers to provide more effective counseling to patients regarding their expected outcomes and rehabilitation course. Furthermore, these findings can aid in the development of a screening tool to better identify these risk factors and optimize them before surgery.