Concomitant Rotator Cuff Repair Research Articles

Arthroscopic Decompression of Calcific Tendinitis of the Shoulder and Repair of Residual Rotator Cuff Defect

Background: Calcific tendinitis is a common source of shoulder pain and represents pathologic deposition of calcium hydroxyapatite within rotator cuff tendon tissue, most commonly the supraspinatus tendon. Indications: Arthroscopic decompression of calcific tendinitis with possible rotator cuff repair is indicated in patients with persistent, debilitating symptoms of pain and/or dysfunction who are recalcitrant to nonoperative treatments, including corticosteroid administration, ultrasound-guided needle barbotage, and/or extracorporeal shockwave therapy. Technique Description: With the patient in a beach chair position, a standard diagnostic shoulder arthroscopy is performed to evaluate for concomitant pathologies. Within the subacromial space, a thorough bursectomy is performed and the area of calcium deposition is localized with a spinal needle. A scalpel may be used to create a small incision through the rotator cuff tendon in line with its fibers to promote egress of calcific debris. Surrounding tissue and loose debris are removed with an arthroscopic shaver. Following decompression, the rotator cuff repair is inspected, and if a bursal-sided or full-thickness tear is identified, an arthroscopic repair is performed with a construct individualized to the specific tear pattern. Results: Surgical treatment conferred greater functional improvement and comparable pain reduction to nonoperative treatments in a systematic review comprised of 27 randomized trials. While the addition of a rotator cuff repair remains controversial, combined excision of calcific tendinitis with concomitant rotator cuff repair led to greater functional outcomes and pain reduction at 2-year minimum follow-up compared with isolated decompression. Conclusion: Calcific tendinitis within the shoulder may be treated successfully with arthroscopic decompression and subsequent repair of a residual rotator cuff defect, followed by a graduated physical rehabilitation program. 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.

Poster 178: Outcomes of SLAP Repair vs. Biceps Tenodesis of SLAP Lesions in Females: A Retrospective Review

Objectives: When surgically managing superior labrum from anterior to posterior (SLAP) tears, there is no consensus on whether SLAP repair or biceps tenodesis yields superior long term outcomes. Additionally, no previous studies have specifically examined outcomes of these procedures in female patients, despite evidence of sex-based differences in recovery following orthopedic surgery. The purpose of this study was to retrospectively compare outcomes after SLAP repair and biceps tenodesis in females. Prior to the start of the study, it was predicted that outcomes between patients who undergo SLAP repair and biceps tenodesis as a treatment will not significantly differ. Methods: Female patients who underwent arthroscopic SLAP repair or biceps tenodesis for treatment of an SLAP lesion between 1/1/2014 and 9/1/2019 at a single institution were retrospectively reviewed. Patients were queried using CPT codes for arthroscopic SLAP repair or biceps tenodesis: for those identified, electronic medical records were reviewed to confirm they met inclusion criteria. Exclusion criteria included: age less than 18 years old at the time of surgery, revision surgery, and concomitant rotator cuff repair at the time of surgery. Patients were contacted at a minimum of two-years post- surgery and asked to complete the standardized American Shoulder and Elbow Surgeons (ASES) score, single assessment numerical evaluation (SANE) survey, and visual analog scale (VAS) for pain. Patients were also given a custom survey assessing return to activity and level of activity following the operation. Patient demographics collected included age at time of surgery, BMI, laterality, and procedure type. Differences in post-operative function between the procedures were assessed using T-tests or Mann- Whitney U tests for numerical data and Chi-Square testing for categorical data. Results: The study included 118 patients. 61 (51.7%) underwent arthroscopic SLAP repair, and 57 (48.3%) underwent open or arthroscopic biceps tenodesis. Comparing demographic data for SLAP repair versus biceps tenodesis groups, mean age was 35.2±8.93 years versus 45.5±10.2 years (p<0.001), mean BMI was 27.5 versus 29.2 (p=0.095), the rates of left shoulder repairs was 30 (50.8%) versus 14 (26.4%), and the rates of right shoulder repairs was 29 (49.2%) versus 39 (73.6%) (p=0.014). Concomitant pathologies were recorded in 68.9% of SLAP repairs and in 88.0% of biceps tenodesis (p=0.030). Concomitant procedures (including bursectomy, capsular release, and acromioplasty) were performed in 74.6% of SLAP repairs and in 92.0% of biceps tenodesis (p=0.033). The two groups showed no differences in two-year ASES scores (81.5 in SLAP repair vs 83.3 in biceps tenodesis, p=0.461), SANE scores (75.6 in SLAP repair vs 79.7 in biceps tenodesis, p=0.344) and VAS scores (20.2 in SLAP repair vs 21.1 in biceps tenodesis, p=0.645). Furthermore, rates of participation in sports prior to surgery was similar (55.4% in SLAP repair vs 42.6% in biceps tenodesis , p=0.251); of those who reported participation prior to surgery, rates of return to participation in sport following surgery was also similar (77.4% in SLAP repair vs 78.3% in biceps tenodesis, p=1.000). Conclusions: This is the first study to evaluate the outcomes of SLAP repair and biceps tenodesis for SLAP lesions in female patients. Female patients who underwent surgical treatment of SLAP lesions with SLAP repair or biceps tenodesis show comparable minimum two-year results with respect to level of function, self-reported pain, and ability to return to sports after these procedures. The incidence of concomitant pathologies and concomitant procedures at the time of SLAP repair and biceps tenodesis differed between the two groups, possibly related to group age disparity. Further research is necessary to define precise treatment indications for this pathology in this specific patient population.

Poster 158: Remplissage Reduces Recurrent Instability in High-Risk Patients with “On-Track” Hill-Sachs Lesions

Objectives: The objective of this study was to compare recurrent instability rates and patient reported outcomes (PROs) between patients with “on-track” Hill-Sachs lesions who underwent ALR alone versus patients who had received ALR with remplissage (ALR+R). Our hypothesis was that performing a remplissage in addition to ALR would decrease the recurrence rate, especially among high-risk subjects such as contact athletes. Methods: We performed a retrospective analysis of patients age 12-40 years old with “on-track” shoulders who underwent ALR+R between Jan 2014 and Dec 2019 at a single institution, with minimum 2-year follow-up. Exclusion criteria included: prior ipsilateral shoulder surgery, >20% glenoid bone loss (GBL), concomitant rotator cuff repair, and connective-tissue disorder. We then identified a cohort of patients meeting the same inclusion and exclusion criteria who had undergone ALR alone. Patient age, gender, follow-up time, first-time dislocation vs. multiple dislocations, and contact sport participation were recorded. GBL, Hills-Sachs Interval (HSI), glenoid track (GT), and DTD were measured from pre-operative MRIs. The patients were then contacted to determine if they had had recurrent instability and/or revision surgery. We also obtained current Western Ontario Shoulder Instability Index (WOSI) and Single Assessment Numeric Evaluation (SANE) scores. Subgroup analysis was performed on “high-risk” patients (DTD <10mm and contact sport participation) from each cohort. Results: The ALR+R cohort had 17 subjects and the ALR cohort had 51 subjects. There were no differences in demographic variables or GBL between cohorts (P>0.05). The ALR+R subjects had larger HSI (14.7mm ± 2.4 vs 5.7mm ± 5.0; P<0.001) and smaller DTD (8.2mm ± 3.2 vs 16.2mm ± 5.7; P<0.001). There were no difference in WOSI (304.2 ± 213 vs 302.4mm ± 344.2; P=0.98) or SANE (84.3 ± 16.6 vs 87.3 ± 8.9; P=0.94) scores between groups. Only 1 (5.9%) subject in the ALR+R cohort had a recurrent subluxation, and there were no dislocations or revision surgeries. The ALR cohort had 7 (13.7%) recurrent dislocations, 3 (5.8%) recurrent subluxations, and 6 (11.8%) revision surgeries. Multivariate analysis indicated that smaller DTD (OR 0.71; 95% CI (0.56 – 0.87); P=0.001) and contact sport participation (OR 8.67; 95% CI (1.19 – 63.35); P=0.033) were associated with increased risk of recurrent instability. After adjusting for contact sport participation and DTD value, the ALR+R cohort had a 98.8% lower risk of recurrent instability compared to the ALR cohort (OR 0.012; 95% CI (0.0001 – 0.22); P=0.003). Among “high risk” subjects, there was only 1 (11.1%) instability event in the ALR+R group and 4 (80%) in the ALR alone group (P=0.023) Conclusions: DTD calculations can be used as an independent predictor of recurrent shoulder dislocation following ALR for treatment of anterior shoulder instability. For patients with “on- track” shoulder lesions, but small DTD measurements (“near-track” lesions), remplissage is protective against recurrent instability events and need for revision surgery. This may be especially true for “high- risk” patients, such as those who participate in contact sports.

Subpectoral Biceps Tenodesis with endobutton fixation in the young population - which technique works best?

Injuries of the long head of the biceps (LHB) tendon are a prevalent source of anterior shoulder pain and are commonly treated with tenodesis. Not only a stable fixation of the LHB but also anatomical restoration of the length-tension relationship plays a central role to provide satisfying functional and cosmetic outcomes, especially in young patients. Here we report the clinical outcomes of two different subpectoral tenodesis techniques using unicortical button fixation. Patients under the age of 50 that were treated between April 2015 and January 2020 with one of the following two subpectoral tenodesis techniques were retrospectively selected and enrolled for a follow-up examination at least 2 years after surgery: Subpectoral in situ tenodesis followed by resection of the intraarticular portion leaving a residual tendon stump in the bicipital groove (group I) vs. tenotomy first followed by resection of the stump and subpectoral tenodesis (group II). Patients that underwent concomitant rotator cuff repair, subsequent shoulder surgery or contralateral biceps surgery were excluded. Clinical outcome was evaluated using the LHB Score, Constant-Murley Score (CMS) and measurements of isometric elbow flexion and forearm supination strength. Sonographic evaluation included assessment of the integrity of the LHB and tenodesis, signs of inflammation within the sulcus or around the tendon and measurements of the distalization of the myotendinous junction (MTJ) of the LHB compared to the non-operated side. Thirty-four patients in group I (24 males, mean age at the time of surgery 40.3 years, mean follow-up 57.2 months) and 24 patients in group II (19 males, mean age 39.8 years, mean follow-up 51.9 months) were evaluated. Total CMS as well as the respective subcategories did not reveal significant differences between groups. Overall LHB score was on average 10 points higher in group I (mean 94 points) compared with group II (mean 84 points) (p=0.016). In the LHB score subcategories, group I showed significantly better results regarding patient-dependent cosmesis (group I mean: 15 points; group II mean: 12 points; p=0.005) and examiner-dependent cosmesis (group I mean: 14 points; group II mean: 10 points; p=0.001). This was substantiated by a significantly higher distalization of the MTJ in group II (group I mean: 3.0 cm; group II mean: 3.8 cm; p=0.030). This study shows that subpectoral in situ tenodesis of the LHB followed by arthroscopic resection of the intraarticular portion provides higher LHB scores and better cosmetic outcome compared with proximal intraarticular tenotomy followed by subpectoral tenodesis.

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

Studies to date comparing biceps tenodesis methods in the setting of concomitant rotator cuff repair (RCR) have demonstrated relatively equivalent pain and functional outcomes. To compare biceps tenodesis constructs, locations, and techniques in patients who underwent RCR using a large multicenter database. Cohort study; Level of evidence, 3. 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. 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. 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.

Depressive and Anxiety Disorders Increase Risk for Recurrent Anterior Shoulder Pain Following Arthroscopic Suprapectoral Biceps Tenodesis

PurposeTo evaluate factors associated with postoperative anterior shoulder pain following arthroscopic suprapectoral biceps tenodesis (ABT) and to determine the clinical impact of postoperative anterior shoulder pain.MethodsA retrospective study of patients that underwent ABT between 2016 and 2020 was conducted. Groups were categorized by the presence (ASP+) or absence (ASP−) of postoperative anterior shoulder pain. Patient-reported outcomes (American Shoulder and Elbow score [ASES], visual analog scale [VAS] for pain, subjective shoulder value [SSV]), strength, range of motion, and complication rates were analyzed. Differences between continuous and categorical variables were tested with two-sample t-tests and chi-squared or Fisher’s exact tests, respectively. Variables collected at different postoperative timepoints were analyzed using mixed models with post hoc comparisons when significant interactions were detected.ResultsA total of 461 (47 ASP+, 414 ASP−) patients were included. A statistically significant lower mean age was observed in the ASP+ group (P < .001). A statistically significant higher prevalence of major depressive disorder (MDD) (P = .03) or any anxiety disorder (P = .002) was observed in the ASP+ group. Prescription medication with psychotropic medications (P = .01) was significantly more prevalent in the ASP+ group. No significant differences were observed in the proportion of individuals reaching the minimal clinical important difference (MCID) for ASES, VAS, or SSV between groups.ConclusionsA pre-existing diagnosis of major depressive disorder or any anxiety disorder, as well as the use of psychotropic medications was associated with postoperative anterior shoulder pain following ABT. Other factors associated with anterior shoulder pain included younger age, participation in physical therapy before surgery, and lower rate of concomitant rotator cuff repair or subacromial decompression. Although the proportion of individuals reaching MCID did not differ between groups, the presence of anterior shoulder pain after ABT resulted in prolonged recovery, inferior PROs, and a higher incidence of repeat surgical procedures. The decision to perform ABT in patients diagnosed with MDD or anxiety should be carefully considered, given the correlation to postoperative anterior shoulder pain and inferior outcomes.Level of EvidenceLevel III, retrospective case-control study. To evaluate factors associated with postoperative anterior shoulder pain following arthroscopic suprapectoral biceps tenodesis (ABT) and to determine the clinical impact of postoperative anterior shoulder pain. A retrospective study of patients that underwent ABT between 2016 and 2020 was conducted. Groups were categorized by the presence (ASP+) or absence (ASP−) of postoperative anterior shoulder pain. Patient-reported outcomes (American Shoulder and Elbow score [ASES], visual analog scale [VAS] for pain, subjective shoulder value [SSV]), strength, range of motion, and complication rates were analyzed. Differences between continuous and categorical variables were tested with two-sample t-tests and chi-squared or Fisher’s exact tests, respectively. Variables collected at different postoperative timepoints were analyzed using mixed models with post hoc comparisons when significant interactions were detected. A total of 461 (47 ASP+, 414 ASP−) patients were included. A statistically significant lower mean age was observed in the ASP+ group (P < .001). A statistically significant higher prevalence of major depressive disorder (MDD) (P = .03) or any anxiety disorder (P = .002) was observed in the ASP+ group. Prescription medication with psychotropic medications (P = .01) was significantly more prevalent in the ASP+ group. No significant differences were observed in the proportion of individuals reaching the minimal clinical important difference (MCID) for ASES, VAS, or SSV between groups. A pre-existing diagnosis of major depressive disorder or any anxiety disorder, as well as the use of psychotropic medications was associated with postoperative anterior shoulder pain following ABT. Other factors associated with anterior shoulder pain included younger age, participation in physical therapy before surgery, and lower rate of concomitant rotator cuff repair or subacromial decompression. Although the proportion of individuals reaching MCID did not differ between groups, the presence of anterior shoulder pain after ABT resulted in prolonged recovery, inferior PROs, and a higher incidence of repeat surgical procedures. The decision to perform ABT in patients diagnosed with MDD or anxiety should be carefully considered, given the correlation to postoperative anterior shoulder pain and inferior outcomes.

Natural History of First-Time Anterior Shoulder Dislocation in Patients Older Than 50 Years: A Study of 179 Patients With a Mean Follow-up of 11 Years.

There is a dearth of knowledge on anterior shoulder instability in older patients. The purposes of this study were to describe the incidence and epidemiology, injury characteristics, and treatment and outcomes in patients ≥50 years old with first-time anterior shoulder instability. We also describe the historical trends in diagnosis and treatment. It was hypothesized that the rates of obtaining a magnetic resonance imaging (MRI) scan and surgical intervention have increased over the past 20 years. Descriptive epidemiology study. An established geographic database was used to identify 179 patients older than 50 years who experienced new onset anterior shoulder instability between 1994 and 2016. Medical records were reviewed to obtain patient characteristics, imaging characteristics, and surgical treatment and outcomes, including recurrent instability. Comparative analysis was performed to identify differences between age groups. Mean follow-up time was 11 years. The incidence of first-time anterior shoulder dislocation in our study population was 28.8 per 100,000 person-years, which is higher than previously reported. Full-thickness rotator cuff tears were found in 62% of the 66 patients who underwent MRI scans. Of all patients, 26% progressed to surgery at a mean time of 1.6 years after injury; 57% of all surgical procedures involved a rotator cuff repair, and 17% included anterior labral repair. All patients who underwent a labral repair also underwent concomitant rotator cuff repair. The rate of recurrent instability for the cohort was 15% at a median of 176 days after the initial instability event. There were no instances of recurrent instability after operative intervention. At an average of 7.5 years after the initial instability event, 14% of patients developed radiographic progression of glenohumeral arthritis. The rate of surgical intervention within 1 year of initial dislocation increased from 5.1% in 1994 to 1999 to 52% in 2015 to 2016. The incidence of first-time anterior shoulder instability in patients aged ≥50 years was 28.8 per 100,000 person-years. Full-thickness rotator cuff tears (62%) were the most common condition associated with anterior shoulder instability, followed by Hill-Sachs lesions (56%). The rate of recurrent instability for the entire cohort was 15%, with no instances of recurrent instability after operative intervention.

Paper 26: Update On Performance And Return To Sport After Biceps Tenodesis In Professional Baseball Players

Objectives:The purpose of this study was to determine the return to sport (RTS) rate and performance upon RTS in professional baseball players who underwent biceps tenodesis. A secondary purpose was to compare the postoperative performance of the group of players who underwent biceps tenodesis to a group of matched controls.Methods:All professional baseball pitchers who underwent biceps tenodesis between 2014 and 2017 were included. Players with concomitant rotator cuff repair were excluded. Demographic and performance data (preoperative and postoperative) were recorded for each player. Performance metrics were then compared between the biceps tenodesis and matched control (no history of biceps tenodesis) groups.Results:14 players (average age 27±4 years; 12 pitchers, 2 position outfielders) were included. Most (79%) were open subpectoral tenodeses while two were arthroscopic biceps transfers, and one was an arthroscopic suprapectoral tenodesis. Fixation methods included cortical button (42%), interference screw (25%), suture anchor (25%) and drill holes (8%). Most players (79%) underwent concomitant procedures (43% underwent SLAP repairs). Among the 14 players, 2 were unable to RTS, 5 RTS but to a lower level, and 7 RTS at the same or a higher level. Thus, overall, while 86% (12/14) were able to RTS, 50% (7/14) RTS at the same or a higher level and 50% were either unable to return or returned to a lower level. Among pitchers, 100% (12/12) were able to RTS, but only 50% (6/12) were able to return to the same or a higher level. For those players who did return to play, it took 245±84 days, and their performance following RTP was unchanged and did not differ from matched controls.Conclusions:While 86% of professional baseball players returned to sport following biceps tenodesis, only 50% returned to the same or higher level. No decline in performance was noted in players who successfully returned. Open subpectoral tenodesis is the most common tenodesis technique performed on professional baseball playersUPLOAD-https://planion-client-files.s3.amazonaws.com/AOSSM/blobs/c7753b55-d658-4847-a8e7-7b70c6cad84f/1/Table_1.docx UPLOAD-https://planion-client-files.s3.amazonaws.com/AOSSM/blobs/961efbc8-aedb-4cfe-b18f-6b8c07d93ec7/1/Table_2.docx UPLOAD-https://planion-client-files.s3.amazonaws.com/AOSSM/blobs/36fbb55a-f22f-468e-a8a3-e7a29979b4b8/1/Table_3.docx None

Outcomes of Biceps Tenotomy Versus Tenodesis During Arthroscopic Rotator Cuff Repair: An Analysis of Patients From a Large Multicenter Database.

Background:Studies to date evaluating biceps tenotomy versus tenodesis in the setting of concomitant rotator cuff repair (RCR) have demonstrated relatively equivalent pain and functional outcomes.Hypothesis:It was hypothesized that a significant difference could be demonstrated for pain and functional outcome scores comparing biceps tenotomy versus tenodesis in the setting of RCR if the study was adequately powered.Study Design:Cohort study; Level of evidence, 3.Methods:The Arthrex Surgical Outcomes System database was queried for patients who underwent arthroscopic biceps tenotomy or tenodesis and concomitant RCR between 2013 and 2021; included patients had a minimum of 2 years of follow-up. Outcomes between treatment types were assessed using the American Shoulder and Elbow Surgeons Shoulder (ASES), Single Assessment Numeric Evaluation (SANE), visual analog scale (VAS) for pain, and Veterans RAND 12-Item Health Survey (VR-12) scores preoperatively and at 3 months, 6 months, 1 year, and 2 years postoperatively. Results were stratified by age at surgery (3 groups: <55, 55-65, >65 years) and sex.Results:Overall, 1936 primary RCRs were included for analysis (1537 biceps tenodesis and 399 biceps tenotomy patients). Patients who underwent tenotomy were older and more likely to be female. A greater proportion of female patients aged <55 years and 55 to 65 years received a biceps tenotomy compared with tenodesis (P = .012 and .026, respectively). All scores were comparable between the treatment types preoperatively and at 3 months, 6 months, and 1 year postoperatively. At 2-year follow-up, patients who received a biceps tenodesis had statistically more favorable ASES, SANE, VAS pain, and VR-12 scores (P ≤ .031); however, the differences did not exceed the minimal clinically important difference (MCID) for these measures.Conclusion:Our findings indicate that surgeons are more likely to perform a biceps tenotomy in female and older patients. Biceps tenodesis provided improved pain and functional scores compared with tenotomy at 2-year follow-up; however, the benefit did not exceed previously reported MCID for the outcome scores. Both procedures provided improvement in outcomes; thus, the choice of procedure should be a shared decision between the surgeon and patient.

Primary Double-Pulley SLAP Repair in an Active-Duty Military Population With Type II SLAP Lesions Results in Improved Outcomes and Low Failure Rates at Minimum Six Years of Follow-up

PurposeTo report mid-term outcomes of active-duty patients younger than the age of 35 years with shoulder type II SLAP lesions following our technique for double-pulley SLAP repair (DPSR).MethodsAll consecutive patients aged 18 to 35 years from January 2014 through December 2015 who underwent primary DPSR by the senior surgeon with complete outcome scores were identified. The clinical significance measures (patient acceptable symptomatic state [PASS], substantial clinical benefit [SCB], minimal clinically important difference [MCID]) have not yet been fully defined for type II SLAP repair procedures, so the values for biceps tenodesis were used as a stand-in. Patients were excluded if they were lost to follow-up of if they underwent a concomitant rotator cuff repair. Outcome measures were completed by patients within 1 week before surgery and at latest follow-up.ResultsOverall, 22 of 41 (53.7%) patients met the inclusion criteria for the study, and all were active-duty military at time of surgery. In total, 21 of 22 (95.5%) patients met the PASS, whereas 20 of 22 (90.9%) achieved SCB and 22 of 22 (100.0%) exceeded the MCID for their operative shoulder as determined by the American Shoulder and Elbow Surgeons score. In total, 19 of 22 (86.4%) patients met the PASS, whereas 22 of 22 (100.0%) achieved SCB and exceeded the MCID for their operative shoulder as determined by the Single Assessment Numeric Evaluation. In addition, 21 of 22 (95.5%) met the PASS, whereas 22 of 22 (100%) achieved SCB and exceeded the MCID for their operative shoulder as determined by the pain visual analog scale. Pre- and postoperative range of motion did not vary significantly. In total, 18 of 22 (81.8%) of patients remained on active duty and were able to return to preinjury work and recreation activity levels. In 2 patients (9.09%), the repair did not heal.ConclusionsMid-term outcomes in this population of young, active-duty patients undergoing DPSR for type II SLAP tears demonstrate a statistically and clinically significant improvement in patient-reported outcomes and an overall return to active-duty rate of 81.8%.Level of EvidenceLevel IV, therapeutic case series.

Update on Performance and Return to Sport After Biceps Tenodesis in Professional Baseball Players.

Background:Bicipital disorders are common among overhead athletes, especially professional baseball players. The ideal treatment for bicipital problems in professional baseball players is unknown.Purpose/Hypothesis:The purpose was to determine the return-to-sport (RTS) rate and performance after RTS in professional baseball players who underwent biceps tenodesis. It was hypothesized that there will be a high RTS rate in this population, with no difference between the biceps tenodesis and control groups in the RTS rate or performance.Study Design:Case series; Level of evidence, 4.Methods:All professional Major League Baseball players who underwent biceps tenodesis between 2014 and 2017 were included. Players with concomitant rotator cuff repair were excluded. Demographic and performance data (preoperative and postoperative) were recorded for each player. Performance metrics were then compared between players with biceps tenodesis and matched controls (no history of biceps tenodesis).Results:Included were 14 players (mean age, 27 ± 4 years; 12 pitchers, 2 position outfielders). Most surgeries (79%) were open subpectoral tenodeses, 2 were arthroscopic biceps transfers, and 1 was an arthroscopic suprapectoral tenodesis. Fixation methods included cortical button (42%), interference screw (25%), suture anchor (25%), and drill holes (8%). Most players (79%) underwent concomitant procedures (43% underwent superior labral anterior-posterior repairs). While 86% (12/14) were able to RTS, 50% (7/14) returned at the same or a higher level, and 50% of the whole study were either unable to return or returned to a lower level. Among pitchers, 100% (12/12) were able to RTS, but only 50% (6/12) were able to return to the same or a higher level. For those players who did RTS, it took 245 ± 84 days, and their performance after RTS was unchanged and did not differ from that of matched controls.Conclusion:Open subpectoral tenodesis was the most common tenodesis technique performed on professional baseball players. While 86% of players returned to sport after biceps tenodesis, only 50% returned to the same or higher level. No decline in performance was noted in players who returned successfully.

Two-Year Clinical Outcomes and Survivorship After Isolated Biceps Tenodesis

The purpose of this study was to evaluate clinical outcomes and survivorship of isolated biceps tenodesis (BT) at a minimum of 2 years and to identify patient-specific factors associated with these outcomes in patients undergoing BT without concomitant rotator cuff repair (RCR). We hypothesized that patient-reported outcomes would be significantly improved on American Shoulder and Elbow Surgeons Survey (ASES) and Single Assessment Numeric Evaluation (SANE), with a high rate of survivorship (>90%) at 2-year follow-up. A retrospective review of an institutional registry was performed to identify patients who underwent BT from July 2016 to December 2017. Patients >18 years old who underwent an open or arthroscopic BT procedure using an interference screw, button, or anchor for underlying bicipital pathology, without a concomitant RCR or shoulder arthroplasty, and were a minimum of 2 years postoperative were included. Patients were administered ASES and SANE questionnaires preoperatively and at final follow-up. Survivorship was evaluated using Kaplan-Meier analysis. Failure was defined as any patient who underwent reoperation related to the index surgery. A total of 110 patients (mean ± standard deviation age, 48.60 ± 12.14 years) who underwent isolated BT with a follow-up of 24.90 ± 3.95 months were included in analysis. There was a significant improvement in ASES and SANE at final follow-up (P < .001), with 81% to 84% of patients achieving minimal clinically important difference (MCID), 72% to 82% achieving substantial clinical benefit (SCB), and 72% to 80% achieving patient-acceptable symptom state (PASS). Worker's Compensation (WC) patients had a decreased likelihood of achieving PASS on ASES (P= .015) and SANE (P= .012). Four cases were deemed failures (3 revision BTs and 1 capsular debridement) at 15.09 ± 9.57 months. WC did not have a significant effect on likelihood of BT failure. Biceps tenodesis provided significant clinical improvement and high rates of survivorship 2 years postoperatively. WC was associated with a decreased likelihood of achieving PASS. These results support the continued use of isolated BT for treating biceps pathology. IV, case series.

Update On Performance And Return To Sport After Biceps Tenodesis In Professional Baseball Players (226)

Objectives:Determine the return to sport (RTS) rate and performance upon RTS in professional baseball players who underwent biceps tenodesis.Methods:All professional baseball pitchers who underwent biceps tenodesis between 2014 and 2017 were included. Players with concomitant rotator cuff repair were excluded. Demographic and performance data (preoperative and postoperative) were recorded for each player. Performance metrics were then compared between the biceps tenodesis and matched control (no history of biceps tenodeses) groups.Results:14 players (average age 27±4 years; 12 pitchers, 2 position outfielders) were included. Most (79%) were open subpectoral tenodeses while one was an arthroscopic biceps transfer and one was arthroscopic suprapectoral. Fixation methods included cortical button (42%), interference screw (25%), suture anchor (25%) and drill holes (8%). Most players (79%) underwent concomitant procedures (43% underwent SLAP repair). Among the 14 players, 2 were unable to RTS, 5 RTS but to a lower level, and 7 RTS at the same or a higher level. Thus, overall, while 86% (12/14) were able to RTS, 50% (7/14) were able to return to the same or a better level and 50% were either unable to return or returned to a lower level. Among pitchers specifically, 100% (12/12) were able to return to play, but only 50% (6/12) were able to return to the same or a higher level. For those players who did return to play, it took 245±84 days, their performance was unchanged and did not differ from matched controls.Conclusions:While 86% of professional baseball players returned to sport following biceps tenodesis, only 50% returned at the same or higher level. No decline in performance was noted in players who successfully returned. Open subpectoral tenodesis is the most common tenodesis technique performed on professional baseball players.

Comparing the outcomes of arthroscopic tenodesis versus tenotomy for the treatment of the long head of biceps tendon pathologies during supraspinatus tendon repair

Aim: Long head of the biceps tendon pathologies are frequently accompany full-thickness rotator cuff tear. The purpose of this study was to compare functional scores, complication rates, and time to return to work after tenotomy and tenodesis who underwent arthroscopic supraspinatus repair (ASR).Methods: Overall, 129 patients who underwent ASR surgery were divided into 2 groups. Group 1 consists of 62 patients underwent biceps tenodesis and group 2 consists of 67 patients underwent biceps tenotomy. We evaluated demographic data, clinical findings, complications and American Shoulder and Elbow Surgeons, Constant Murley, Visual analogue scale and 36-item Short Form subscale scores. Results: Mean follow-up time was 13.68±4.22 months. Mean postoperative and preoperative-postoperative differences of ASES, CM, VAS and SF-36 subscale scores were not significantly different between two groups. Popeye sign was positive for 13 (19.4%) patients in group 2, however, none of patients in group 1 was positive (p&amp;lt;0.001). Other complications were not significantly different between two groups.Conclusion: The results show that arthroscopic biceps tenotomy and tenodesis are both viable treatments for proximal biceps tendon pathology, yielding similar clinical outcomes in the context of concomitant rotator cuff repair. Tenotomy can be chosen instead of tenodesis which is technically more difficult and expensive.

Early Versus Delayed Active Range of Motion After Open Subpectoral Biceps Tenodesis.

Background:Little is known regarding the effect of early active elbow range of motion (ROM) protocols on failure rates and outcomes after open subpectoral biceps tenodesis.Hypothesis:We hypothesized that patients managed using an early active ROM protocol after open subpectoral biceps tenodesis would demonstrate similar failure rates and functional outcomes compared to patients managed using a traditional delayed active ROM protocol.Study Design:Cohort study; Level of evidence, 3.Methods:We evaluated 63 patients who underwent open subpectoral biceps tenodesis with unicortical suture button fixation. Based on surgeon preference, 22 patients were managed using an early active motion protocol consisting of no restrictions on elbow flexion or forearm supination, while 41 patients were managed using a delayed motion protocol postoperatively. Primary outcome measures included failure of biceps tenodesis and American Shoulder and Elbow Surgeons (ASES) and Single Assessment Numeric Evaluation (SANE) scores. Secondary outcomes included shoulder and elbow ROM at 6 months postoperatively.Results:The mean follow-up for the 63 patients was 24.2 months postoperatively. One patient (2.4%) in the delayed active motion cohort and no patients in the early active motion cohort experienced failure. Final outcome scores as well as 6-month shoulder and elbow ROM indicated excellent functional outcomes, with no significant difference between motion cohorts. The median postoperative ASES scores were 97.99 in the early active motion cohort (mean ± standard deviation [SD], 95.49 ± 7.68) and 95.42 in the delayed motion cohort (mean ± SD, 90.93 ± 16.08), while median postoperative SANE scores were 96 in the early motion cohort (mean ± SD, 94.23 ± 6.68) and 95 in the delayed motion cohort (mean ± SD, 88.39 ± 17.98). Subgroup analysis demonstrated no significant difference in outcome scores based on the performance of concomitant rotator cuff repair or hand dominance.Conclusion:Early active ROM after open subpectoral biceps tenodesis with unicortical suture button fixation resulted in low failure rates and excellent clinical outcomes, comparable to the results of patients managed using delayed active ROM protocols. This suggests that patients undergoing open subpectoral biceps tenodesis may be managed using either early or delayed active motion protocols without compromising functional outcome.

Relative Efficacy of Three of Nonsurgical Treatments for Calcific Tendinitis: Physical Therapy vs Steroid Injection vs Ultrasound-Guided Aspiration

Objectives:Calcific tendinitis of the shoulder is a painful condition characterized by the presence of calcium deposits within the tendons of the rotator cuff (RTC) that accounts for up to 7% of cases of shoulder pain1. The most common conservative treatments typically include physical therapy (PT), corticosteroid injection (CSI), or ultrasound-guided aspiration (USA). When conservative management fails, the patient may require arthroscopic surgery to remove the calcium with concomitant rotator cuff repair. The purpose of this study was to characterize the failure rates, defined as the need for surgery, of each of these three methods of conservative treatment, as well as to compare post-operative improvement in patient-reported outcomes (PROs) – including subjective shoulder values (SSV) and visual analog scale (VAS) pain scores – based on the type of pre-operative conservative intervention provided. A secondary aim was to compare post-operative range of motion (ROM) outcomes between groups that failed conservative management. We hypothesized that all preoperative conservative treatments would have equivalent success rates, PROs, and ROM. Bosworth B. Calcium deposits in the shoulder and subacromial bursitis: a survey of 12122 shoulders. JAMA. 1941;116(22):2477-2489. Methods:A retrospective review of all patients who were diagnosed with calcific tendinitis at our institution treated among 3 fellowship trained orthopedic surgeons between 2009 and 2019 was performed. VAS, SSV, and ROM in forward flexion (FF) and external rotation (ER) was abstracted from the medical records. Scores were recorded at the initial presentation as well as final post-operative follow-up visit for those who underwent surgery. The conservative treatment method utilized by each patient was recorded and included PT, CSI, or USA. Failure of conservative management was defined as eventual progression to surgical intervention. Statistical analysis included chi-square, independent t test and ANOVA. Descriptive statistics were used to report data. A p<0.05 was considered to be statistically significant.Results:239 patients diagnosed with calcific tendinitis were identified in the study period with mean age of 54 years and follow up of at least 6 months. In all, 206 (86.2%) patients underwent a method of conservative treatment. Of these patients, 71/239 (29.7%) underwent PT, 67/239 (28%) attempted CSI, and 68/239 (28.5%) underwent USA. The overall failure rate across all treatment groups was 29.1%, with injections yielding the highest success rate of 54/67 (80.6%). Physical therapy saw the highest failure rate, with 26/71 (36.7%) proceeding to surgical intervention. Patients undergoing physical therapy were statistically more likely to require surgery compared to those undergoing corticosteroid injection (RR 1.88, p= 0.024). Of all 93 patients who underwent surgery, VAS, SSV, ROM improved significantly in all groups. On average, VAS decreased by 4.02 points (6.3 to 2.3), SSV increased by 33 points (51 to 84), FF improved by 13.8º, and ER improved 8.4º between the pre- and post-operative visits (p<0.05). The 33 patients who did not attempt a conservative pre-operative treatment demonstrated the largest post-operative improvement in VAS (-6.00), which was significantly greater than those who previously attempted PT (-3.33, p<0.05). There was a trend towards greater improvement in SSV in the pre-operative PT group (45 to 81) compared to others, but this did not reach statistical significance (p=0.47). Range of motion was not significantly affected by the method of pre-operative conservative intervention.Conclusions:Conservative treatment in the form of physical therapy, corticosteroid injection, and ultrasound-guided aspiration is largely successful in managing calcific tendinitis of the shoulder. Of these, PT demonstrated the highest rate of failure in terms of requiring surgical management. PRO improvement varied among the conservative modalities used, however patients who did not attempt conservative management experienced the greatest improvements following surgery. If surgery is necessary following failed conservative treatment, excellent outcomes can be expected with significant improvements in ROM and PROs. This information should be considered by the surgeon when deciding whether to recommend conservative treatment for the management of calcific tendinitis, as well as which specific method to employ.

Predictive factor for failure of conservative management in the treatment of calcific tendinitis of the shoulder

Objectives:Calcific tendinitis of the shoulder is a painful condition characterized by the presence of calcium deposits within the tendons of the rotator cuff (RTC) and accounts for up to 7% of all presentations of shoulder pain. Conservative treatment with physical therapy (PT) and corticosteroid injection is often the first line treatment. When conservative management fails, arthroscopic surgery for removal of the calcium may be considered. Surgical removal is often followed by rotator cuff repair to address the resulting tendon defect. This study was performed to assess predictive factors for failure of conservative management as well as to characterize the rate of rotator cuff repair in the setting of calcific tendinitis. We hypothesize that larger calcific lesion would have a higher likelihood to fail conservative treatment and the majority of patients requiring surgery will require a concomitant rotator cuff repair.Methods:A retrospective review of patients who were diagnosed with calcific tendinitis at our institution between 2009 and 2019 was performed. Demographics, comorbidities, pain score (VAS), ASES, ROM and patient-reported quality of life measures were recorded and analyzed. All patients underwent a radiograph and MRI. Size of the calcific lesion was measured based on its largest diameter on radiograph. Statistical analysis included chi-square, independent t test and ANOVA. Descriptive statistics were used to report data. p<0.05 was considered to be statistically significant.Results:239 patients were identified in the study period; 127 (53.1%) were female. Mean age was 54 years and BMI 29.2 with mean follow up of 6 months. Preoperative pain score was 6.3 and ASES score was 47.9. 160 had an intact RTC (67.2%) and 78 had a partial RTC tear (32.8%). The calcific lesion was located in the supraspinatus in 148 patients (63.8%), infraspinatus in 32 patients (13.8%), subscapularis in 9 patients (3.9%), teres minor in 1 patient (0.4%) and combined tendons in 42 patients (18.1%). 93/239 (38.9%) patients failed conservative treatment after an average of 4.4 months necessitating surgical management. Failure rate for PT was 36.6% (24/71), for subacromial corticosteroid injection was 31.6% (25/79) and 33.8% (24/71) for ultrasound guided aspiration. Among patients who underwent surgery the majority of patients, 77/93 (82.8%) required a concomitant rotator cuff repair. Sub-analysis demonstrates that calcific lesions > 1 cm was significantly associated with failure of conservative treatment (odds ratio=2.81, 95% CI 1.25-6.29, p<0.05). All patients who underwent surgery demonstrated significant improvements in pain scores (6.3 to 2.3 VAS), ASES (47.9 to 90.49), forward flexion (133° to 146.8°) and external rotation (49.2° to 57.6°) (p<0.05) postoperatively.Conclusions:Patients with calcific lesions >1 cm have a 2.8x-increased likelihood of failing conservative treatment in the setting of calcific tendinitis of the shoulder. The majority of patients who undergo surgical management for removal of the calcific deposit will require a concomitant rotator cuff repair and have significant improvements in shoulder pain and function. While conservative management is often considered a first-line treatment, the size of the lesion may play a significant role regarding whether conservative treatment will be successful, and patients should be counseled accordingly. Once surgery is decided, orthopedic surgeons should also be aware of the high likelihood of concomitant rotator cuff repair for preoperative planning and discussion.

Predicting Patient Satisfaction With Maximal Outcome Improvement After Biceps Tenodesis.

The goal of this study was to determine the threshold for achieving maximal outcome improvement (MOI) on the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and Constant-Murley (CM) questionnaires that predict satisfaction after isolated biceps tenodesis without concomitant rotator cuff repair. A retrospective analysis of prospectively collected data was performed for patients undergoing isolated biceps tenodesis from 2014 to 2017 at a single institution with minimum 6-month follow-up. Receiver operating characteristic curve analysis was used to determine thresholds for MOI for the ASES, SANE, and CM questionnaires. Stepwise multivariate logistical regression analysis was performed to identify predictors for achieving the threshold for MOI. A total of 123 patients were included in the final analysis. Receiver operating characteristic analysis determined that achieving 43.1%, 62.1%, and 61.4% MOI was the threshold for satisfaction for the ASES, SANE, and CM questionnaires, respectively. Regression analysis showed that concomitant superior labrum anterior-posterior (SLAP) repair was predictive of achieving MOI on the ASES and SANE questionnaires, whereas partial rotator cuff tear was predictive of achieving MOI on the CM questionnaire (P<.05 for both). Further, workers' compensation status, diabetes, history of ipsilateral shoulder surgery, and hypertension were negative predictors of achieving MOI on the SANE and CM questionnaires (P<.05 for all). Achieving MOI of 43.1%, 62.1%, and 61.4% is the threshold for satisfaction after biceps tenodesis for the ASES, SANE, and CM questionnaires, respectively. Concomitant SLAP repair was positively predictive of achieving MOI, whereas workers' compensation status, diabetes, history of ipsilateral shoulder surgery, and hypertension were negative predictors. [Orthopedics. 2021;44(3):e359-e366.].

Clinical outcome comparison of suprapectoral and subpectoral tenodesis of the long head of the biceps with concomitant rotator cuff repair: A systematic review.

Simultaneous repairs of rotator cuff and biceps tenodesis can be managed by tenodesis of long head of biceps tendon to a subpectoral or suprapectoral area. This review investigated long head of biceps tendon tenodesis with concomitant rotator cuff repair and evaluated the clinical outcomes and incidences of complications based on tenodesis location. Medline, Cochrane, and Embase databases were searched for published, randomized or nonrandomized controlled studies and prospective or retrospective case series with the phrases "suprapectoral," "subpectoral," "tenodesis," and "long head of biceps tendon". Those with a clinical evidence Level IV or higher were included. Non-English manuscripts, review articles, commentaries, letters, case reports, and sole long head of biceps tendon tenodesis articles were excluded. From 481 studies, 13 were chosen. In total, 1194 subpectoral and 2520 suprapectoral tenodesis cases were investigated. Postoperative Constant-Murley and American Shoulder and Elbow Surgeons mean scores showed similar good results. In terms of complication incidences, while transient nerve injuries were more commonly seen in patients with subpectoral tenodesis, persistent bicipital pain and Popeye deformity are mostly seen in patients with suprapectoral tenodesis. Biceps tenodesis to suprapectoral or subpectoral area with concomitant rotator cuff repair demonstrated similar outcomes. Popeye deformity and persistent bicipital pain were higher in suprapectoral area and transient neuropraxia was found to be higher in subpectoral area.Level of evidence: IV.

Cost Comparison of Open and Arthroscopic Treatment Options for SLAP Tears

PurposeTo identify cost drivers of open biceps tenodesis, arthroscopic biceps tenodesis, and arthroscopic SLAP repair in the setting of isolated SLAP tears and to perform a direct cost comparison between the procedures.MethodsThe 2014 State Ambulatory Surgery and Services Databases from 6 US states were used. Cases with Current Procedural Terminology codes 23430 (tenodesis of long tendon of biceps), 29807 (shoulder arthroscopy, repair of SLAP lesion), and 29828 (shoulder arthroscopy, biceps tenodesis) were selected, excluding patients who were >50 years old or had a concomitant rotator cuff repair. Generalized linear models were used to model costs based on surgical and patient variables.ResultsThe mean patient age was 41.8 years for open biceps tenodesis, 31.6 for arthroscopic SLAP repair, and 41.3 for arthroscopic biceps tenodesis (P < .001). Open biceps tenodesis had cost reductions of $5,664 over arthroscopic biceps tenodesis (P = .001) and $2,320 over arthroscopic SLAP repair (P = .043). Male sex was associated with $3,798 more in costs (P < .001), presence of ≥1 comorbidities added $1,829 (P = .002), and each minute in the operating room added $37 (P < .001). Operative time for open biceps tenodesis averaged 114 minutes, and both arthroscopic procedures averaged 94 minutes (P < .001). Low-volume facilities were associated with $5,536 higher costs for arthroscopic biceps tenodesis (P = .001).ConclusionIn patients aged ≤50 years with isolated SLAP tears, open biceps tenodesis provides cost savings over arthroscopic methods of treatment. There was no significant cost difference between arthroscopic SLAP repairs and arthroscopic biceps tenodesis. Given the increased emphasis on cost containment, surgeons should be aware of the procedural costs associated with the treatment of SLAP tears.Level of EvidenceIII, retrospective cohort study.