Long Head Of The Biceps Tenotomy Research Articles

Biceps tenotomy vs. tenodesis in patients undergoing transtendinous repair of partial thickness rotator cuff tears

BackgroundPatients with partial-thickness rotator cuff tears (PTRCTs) often present with concurrent pathology of the long head of the biceps (LHB) tendon. To address both conditions simultaneously, LHB tenotomy or tenodesis can be performed at the time of arthroscopic rotator cuff repair (RCR). This study aims to compare postoperative shoulder active range of motion (AROM) and complications following transtendinous RCR with concurrent LHB tenodesis or tenotomy. MethodsA total of 90 patients with PTRCTs met inclusion criteria for this study. Patients who underwent tear-completion-and-repair, revision surgery, or open repair of the LHB tendon were excluded. Patients were stratified into tenotomy, arthroscopic suprapectoral tenodesis, or no biceps operation cohorts and were propensity matched 1:1:1 on age, sex, body mass index (BMI), and smoking status. Primary outcome measures included AROM in forward flexion, abduction, external rotation, and internal rotation at 6 weeks, 3 months, and 6 months postoperatively. The development of severe stiffness and rates of rotator cuff retear at final follow-up were recorded as secondary outcomes. ResultsWhen comparing the tenotomy and tenodesis cohorts, tenotomy patients were found to have increased AROM at 3 months in forward flexion (153.2° vs 130.1°, p=0.004), abduction (138.6° vs 114.2°, p=0.019), and external rotation (60.4° vs 43.8°, p=0.014), with differences in forward flexion remaining significant at 6 months (162.4° vs 149.4°, p=0.009). There were no significant differences in interval rates of recovery in any plane between cohorts. Additionally, there were no significant differences in rates of symptomatic retears between groups (p=0.458). Rates of severe postoperative stiffness approached but did not achieve statistical significance between tenotomy (4.2%) and tenodesis (29.2%) cohorts (p=0.066). Smoking status was a significant predictor of severe stiffness (odds ratio, 13.69; p=0.010). ConclusionDespite significant differences in absolute AROM between cohorts, the decision to perform tenotomy or tenodesis was not found to differentially affect rates of AROM recovery for patients undergoing arthroscopic transtendinous RCR for PTRCT. Notably, however, transient stiffness complications were more commonly observed in smokers, and data trends suggested an increased risk of stiffness for patients undergoing LHB tenodesis. Overall, postoperative stiffness is likely multifactorial and attributable to both patient- and procedure-specific factors, and LHB tenotomy may be more appropriate for patients with risk factors for developing stiffness postoperatively.

The Association of Tobacco Smoking and Level of Apoptosis in the Long Head of the Biceps Chronic Tendinopathy—An Immunohistochemical Study

Background: The substances present in cigarette smoke have a negative impact on cellular integrity and metabolism, can reduce blood flow to tissues, and can disrupt collagen synthesis. Ultimately this can lead to cell death, which clinically may result in impaired tendon healing and the onset of chronic tendinopathy. Within the shoulder, the exact association between the extent of apoptosis in the long head of the biceps (LHB) tendon and harmful factors like cigarette smoke remains unclear. Objectives: The purpose of this study was to investigate the connection between smoking, the degree of apoptosis in LHB tendinopathy, and the long-term outcomes of surgical treatment. Design: Observational, retrospective study. Methods: This study included 22 consecutive patients who had undergone arthroscopic biceps tenodesis or tenotomy for symptomatic LHB tendinopathy with or without concomitant rotator cuff tears (RCT). The intra-articular LHB tendon remnants were histologically examined by measuring the level of expression of apoptotic cell markers such as BCL2, cleaved caspase 3, and p53. Pre- and postoperative clinical outcomes were analyzed by collecting patient report outcome measures such as the American Shoulder and Elbow Surgeons (ASES) score and the Visual Analogue Scale (VAS) for pain. Results: The smokers group had a mean pack-year history of 13.12 (SD = 9.94), mean number of cigarettes per day of 14.77 (SD = 4.64), and a mean smoking duration of 16.38 (SD = 10.1) years. Among the smoking indexes, the number of cigarettes per day showed a positive correlation with Snyder classification (p = 0.0459, rho = 0.3682). Non-smokers and smokers did not show a statistically significant difference in the expression indexes of BCL2, cleaved caspase 3, or p53 (p = 0.4216, p = 0.5449, p = 0.5613, respectively). However, the cleaved caspase 3 expression index showed a negative correlation with the severity of rotator cuff lesions in the total population (p = 0.0193, rho = −0.4651). Conclusions: While apoptotic processes in the LHB tendon were observed, no significant association was found between tobacco smoking, the extent of apoptosis, and clinical outcomes. However, the expression of the apoptotic marker cleaved caspase 3 correlated with the severity of rotator cuff pathology. Furthermore, active smoker status was associated with worse clinical outcomes in terms of pain following LHB tenodesis or tenotomy.

Arthroscopic Subscapularis Repair With Preserved Biceps Anatomy

Arthroscopic subscapularis repair continues to improve with the advancement of surgical technique and critical focus on careful intraoperative evaluation. As identification of these tears increases, there is an expected increase in repair rates as well. Anatomically, the upper border of the subscapularis and the long head of the biceps (LHB) tendon are in close relation. Many surgeons have advocated concomitant LHB tenotomy versus tenodesis in conjunction with operative subscapularis tears. We hypothesized that in the setting of a preserved anatomic biceps pulley and no LHB pathology, isolated subscapularis repair would result in excellent clinical outcomes when compared with subscapularis repair and biceps tenotomy or tenodesis.

The effect of biceps tenotomy on superior humeral migration in arthroscopic repaired full-thickness supraspinatus tears

Lesions of the long head of the biceps (LHB) tendon are a prevalent injury that frequently coexists with rotator cuff injuries. This study aimed to assess the effect of supraspinatus (SST) repair with concurrent LHB tenotomy on superior migration of the humeral head. The acromiohumeral distance (AHD) was determined via ultrasound to evaluate the superior migration of the humeral head. The study population was retrospectively recruited from patients who underwent unilateral arthroscopic repair of isolated degenerative full-thickness SST tears between January 2017 and December 2019. Patients were divided into 2 subgroups based on whether they underwent LHB tenotomies during arthroscopy. While 37 patients underwent arthroscopic single-row SST repair, the other 33 patients underwent arthroscopic single-row SST repair with LHB tenotomy. The subject group consisted of people who had undergone arthroscopic shoulder surgery. Contralateral shoulders without rotator cuff injuries were included in the control group. The AHD and SST thicknesses of patients were examined via the ultrasound in both groups and subgroups. The mean age in the SST repair group was 55.52±4.58 years (range, 46-63 years), whereas it was 58.24±3.98 (range, 52-73 years) in the SST repair+LHB tenotomy group. In the SST repair group, 57.6% of patients were female and 42.4% were male, whereas 56.8% and 43.2% were in the SST repair+LHB tenotomy group, respectively. The mean body mass index was 28.06±1.31 kg/m2 (range, 25.7-31.2 kg/m2) in the SST repair group and 28.95±1.79 kg/m2 in the SST repair+LHB tenotomy group. Groups were not different for sex, surgery side, dominant side, tear size, and follow-up time; however, the SST repair+LHB tenotomy group had significantly higher mean age and body mass index than the SST repaired group. The mean AHD value and SST thickness were significantly less in both the rotator cuff repair group and the rotator cuff repair+LHB tenotomy group compared to the healthy shoulder. The mean AHD value was significantly lower in the SST repaired+LHB tenotomy group than in the SST repair group (P=.02). The AHD was narrowed in patients who underwent LHB tenotomy and radiologically demonstrated the depressor effect of the LHB tendon on the humeral head. As a secondary outcome, we demonstrated that regardless of tenotomy, AHD could not be restored in patients who underwent arthroscopic single-row SST repair.

Complications of Long Head of the Biceps Tenotomy in Association with Arthroscopic Rotator Cuff Repair: Risk Factors and Influence on Outcomes.

Background: This study aims to report the rate of biceps-related complications after LHB tenotomy, investigating related risk factors and their influence on the outcome. The hypothesis is that these complications have a limited clinical influence. Methods: A single-center prospective observational study was performed between 2015 and 2017 on consecutive patients who underwent RCR associated with LHB tenotomy. Patients were clinically and radiologically evaluated preoperatively, at six months and one year, and screened for postoperative popeye deformity, cramps, and bicipital discomfort. Each complication was analyzed for the following risk factors: age, sex, body mass index (BMI), dominant arm, manual work, tear patterns, and tendon healing. Finally, the clinical outcome was compared between patients with and without complications. Results: 207 patients were analyzed. Cramps, popeye deformity, and discomfort, were respectively, present in 16 (7.7%), 38 (18.4%) and 52 (25.1%) cases at six months and 17 (8.2%), 18 (8.7%) and 24 (11.6%) cases at one year. Cramps were associated with lower age (p = 0.0005), higher BMI (p = 0.0251), single tendon tear (p = 0.0168), manual work (p = 0.0086) at six months and manual work (p = 0.0345) at one year. Popeye deformity was associated with male sex at six months (p < 0.0001). Discomfort was associated with lower age (p = 0.0065), manual work (p = 0.0099), popeye deformity (p = 0.0240) at six months and manual work (p = 0.0200), single tendon tear (p = 0.0370), popeye deformity (p = 0.0033) at one year. Patients without complications showed a significant higher Constant score, pain and subjective shoulder value (SSV) (75.3 vs. 70.4, p = 0.00252; 0.9 vs. 1.9, p < 0.00001; 80.2 vs. 76.4; p = 0.00124) at six months and pain and SSV (0.6 vs. 2.0; p = 0.00044; 91.1 vs. 77.8; p ≤ 0.00001) at one year. Conclusions: Younger age, male sex, higher BMI, manual work, and single tendon tears are risk factors associated with the development of biceps-related symptoms during the first year after tenotomy in association with rotator cuff repair. Nevertheless, the clinical influence of these symptoms on shoulder outcomes is limited.

Management of normal long head of the biceps tendon in isolated grade-1 supraspinatus tear: Research protocol for a multicenter prospective single-blind randomized study

BackgroundThe long head of the biceps (LHB) tendon is a common locus of pain in rotator cuff tear and of residual pain after tendon repair. Therefore, systematic LHB tenotomy, with or without tenodesis, is usually recommended. However, the recent literature suggests that long-term functional results of supraspinatus tendon repair are comparable between conservation of a normal biceps and tenotomy. The study objective is to compare functional results between sectioning and sparing a normal LHB in treating isolated grade-1 supraspinatus tendon tear. The study hypothesis is that sparing the normal LHB is clinically preferable to sectioning in the particular case of distal supraspinatus tear. Methods and analysisA French nationwide prospective single-blind randomized clinical study will include 194 patients undergoing arthroscopic repair of grade-1 supraspinatus tear with normal LHB. They will be randomized to 2 parallel groups: LHB sparing and sectioning. The main endpoint is Constant-Murley score, and secondary endpoints comprise ASES and SSV scores, clinical assessment of the biceps, pain on VAS, ultrasound assessment of cuff repair healing and conserved LHBs, impact on return to work and sport, pathologic assessment of sectioned LHBs, and analysis of risk factors for cuff repair failure. Ethical approval and publicationThe protocol has been approved by the data protection committee (art.L.1122-1) and meets the criteria of the Declaration of Helsinki and of the SPIRIT statement defining standard protocol items for clinical trials. Results will be published in a peer-reviewed journal. Level of evidencenot applicable.

Complications liées au biceps après ténotomie associée à la réparation arthroscopique de la coiffe des rotateurs : facteurs de risque et influence clinique

Lots of studies investigated differences between tenotomy and tenodesis, while just a few specifically investigated the results of tenotomy in association with rotator cuff repari (RCR). Our aim is to report the rate of biceps related complications after long head of the biceps (LHB) tenotomy in association with RCR. A single-center prospective observational study was performed between 2015 and 2017 on consecutive patients who underwent RCR associated with LHB tenotomy. Patients were clinically evaluated preoperatively, at 6 months (also with ultrasound) and 1 year, and screened for postoperative popeye deformity, cramps and bicipital discomfort. Each complication was analyzed for the following risk factors: age, sex, BMI, dominant arm, manual work, tear kind, tendon healing. Finally, clinical outcome was compared between patients with at least one complication and without complications. Two hundred and seven patients were analyzed. Cramps, popeye deformity, and discomfort, were, respectively, present in 16 (7.7%), 38 (18.4%) and 52 (25.1%) cases at 6 months and 17 (8.2%), 18 (8.7%) and 24 (11.6%) cases at 1 year. Cramps were associated with lower age (1 year-increase OR = 0.88–95%CI, 0.81–0.96−), higher BMI (1 point-increase OR = 1.1–95% CI, 1.02–1.23−), single tendon tear (P = 0.0168), manual work (OR = 5.0–95%CI, 1.5–16.0−) at 6 months and manual work (OR = 2.9–95% CI, 1.1–8.3−) at 1 year. Objective popeye deformity was associated with male sex at 6 months (OR = 6.9–95%CI, 3.0–15.5−). Discomfort was associated with lower age (OR = 0.94–95%CI, 0.90–0.98−), manual work (OR = 2.3–95%CI, 1.2–4.3−), popeye deformity (OR = 2.3–95%CI, 1.1–4.9−) at 6 months and manual work (OR = 2.8–95% CI, 1.1–6.6−), single tendon tear (OR = 4.9–95%CI, 1.1–21.3−), popeye deformity (OR = 3.4–95% CI, 1.1–10.7−) at 1 year. Patients without complications showed a significant higher Constant score, pain and SSV (75.4 vs. 70.4, P = 0.00252 ; 0.9 vs. 1.9, P < 0.00001 ; 80.2 vs. 76.4 ; P = 0.00124) at 6 months, pain and SSV (0.6 vs. 2.0; P = 0.00044; 91.1 vs. 77.8; P = <.00001) at 1 year. Younger age, higher BMI, manual work and single tendon tears are risk factors associated with biceps related symptoms during the first year. Popeye occurs more frequently in males and is associated with discomfort. Nevertheless, the short-term clinical influence of biceps complications on shoulder outcome is very limited.

Long Head of Biceps Tenotomy Is Not Inferior to Suprapectoral Tenodesis in Arthroscopic Repair of Nontraumatic Rotator Cuff Tears: A Multicenter, Non-inferiority, Randomized, Controlled Clinical Trial

To determine if long head of the biceps (LHB) tenotomy is not inferior to suprapectoral LHB tenodesis when performed in conjunction with arthroscopic repair of small- to medium-sized nontraumatic rotator cuff tears. This multicenter, randomized, non-inferiority trial recruited 100 participants older than 50 years who had a supraspinatus and/or infraspinatus tear sagittally smaller than 3 cm and arthroscopically confirmed LHB pathology. During arthroscopic rotator cuff repair, we randomized 48 patients to undergo suprapectoral LHB tenodesis and 52 patients to undergo LHB tenotomy. Data were collected preoperatively and at 6 weeks, 3 months, and 1 year postoperatively. The primary outcome was non-inferiority of the Constant-Murley score (CMS) at 1-year follow-up. Secondary outcomes included the Dutch Oxford Shoulder Score; Disabilities of the Arm, Shoulder and Hand questionnaire; Popeye deformity; elbow flexion strength index; arm cramping pain; and quality of life (EQ-5D score). The integrity of the rotator cuff repair was assessed with magnetic resonance imaging. Differences between intervention groups were analyzed by mixed modeling. The mean CMS in the LHB tenotomy group improved from 44 (95% confidence interval [CI], 39-48) to 73 (95% CI, 68-79). In patients with LHB tenodesis, the mean CMS improved from 42 (95% CI, 37-48) to 78 (95% CI, 74-82). The difference between groups at 1-year follow-up was 4.8 (97.5% CI, -∞ to 11.4), with a P value for non-inferiority of .06. The secondary outcomes also improved over time, with no remarkable differences between groups. A Popeye deformity occurred in 33% of tenodesis patients and 47% of tenotomy patients (P= .17). Tenotomy was performed with a shorter operative time (73 minutes vs 82 minutes, P= .03). Magnetic resonance imaging showed a recurrent rotator cuff tear in 20% of all cases. Although statistically "inconclusive" regarding non-inferiority of the CMS at 1-year follow-up, any observed differences between patients with LHB tenotomy and those with LHB tenodesis in all outcome scores were small. Level I, randomized controlled trial and treatment study.

The Saber Technique for Biceps Tenotomy

Long head of the biceps (LHB) pathology is a prevalent cause of shoulder pain. Arthroscopic tenotomy and tenodesis are performed for treatment at increasing frequency. When LHB pathology is the only glenohumeral intra-articular pathology that needs to be addressed, and an LHB tenotomy or subpectoral LHB tenodesis is planned, it is unnecessary and potentially harmful to establish an anterior rotator interval portal. The objective of this Technical Note is to describe a minimally invasive technique for LHB tenotomy at the supraglenoid tubercle without the need for establishing an accessory portal.

Popeye sign: Frequency and functional impact.

There is currently no consensus on the choice between tenotomy and tenodesis of the long head of the biceps tendon in rotator cuff repair. The Popeye sign is often seen as a drawback of tenotomy. The main objective of the present study was to determine the frequency and clinical impact of the Popeye sign. The Popeye sign is rarely found clinically, and shows little functional impact following tenotomy. A single-center non-randomized prospective study was conducted between February and October 2015 in all patients undergoing rotator cuff surgery. Patients without surgery on the long head of the biceps tendon were excluded. The rate of Popeye sign was assessed 6 months postoperatively. Tenotomy patients with and without Popeye sign were compared in terms of pain on visual analog scale≤3, gain in range of motion, improvement in subjective shoulder value, discomfort or cramps and gain in Constant score. Seven of the 55 patients included (15.2%) showed postoperative Popeye sign. There were no differences between the groups with and without Popeye sign on any of the assessment criteria except for a significantly greater improvement in mean Constant range of motion score in the Popeye group: gain of 13.8 versus 3.8 points; p=0.01. The Popeye sign was relatively rarely observed. Functional impact in the present study was slight. Longhead of the biceps tenotomy is a justifiable treatment option in case of associated rotator cuff tear repair. IV, prospective non-randomized.

Arthroscopic Tenotomy of the Long Head of the Biceps Tendon

The tendon of the long head of the biceps (LHB) can become a source of pain and subsequent shoulder disability as due to several pathologies, such as tendonitis, synovitis, subluxation, dislocation, and hypertrophy with intra-articular entrapment. Operative treatment for a symptomatic LHB tendon includes tenotomy or tenodesis; however, there is considerable debate over which technique is optimal. The decision to use one technique over the other depends on patient factors (age, health condition, activity, and hope), structural compromise to the biceps tendon, and concomitant shoulder pathology. The benefits of tenotomy are technical ease, minimal risk of persistent tenosynovitis, no need for an implant, postoperative protection, and tendon-bone healing. Past studies have demonstrated either no difference or a difference less than the reported minimal clinically important difference in postoperative outcome scores between rotator cuff repair (RCR) with LHB tenotomy and tenodesis. Additionally, there were no differences in postoperative patient satisfaction, fatigue-related cramping or elbow flexion strength after RCR with LHB tenotomy or tenodesis. However, there are significant differences in the degree of cosmetic deformity and forearm supination strength between RCR with LHB tenotomy and tenodesis. LHB tenotomy is a viable option for treatment of symptomatic LHB tendon for the patients without a high demand for cosmetic deformity and forearm supination strength.

Biceps Tenotomy Does not Affect the Functional Outcomes of Patients Treated with Spacer Implantation Due to Massive Irreparable Rotator Cuff Tears

Background:Lesions of the long head of the biceps (LHB) tendon are frequently associated with massive rotator cuff tears (RCT) and may be responsible for shoulder pain and disability.Objective:This study aimed to evaluate functional outcomes of arthroscopic biodegradable spacer implantation with or without biceps tenotomy as treatment for persistent shoulder dysfunction and pain due to a massive irreparable RCT.Methods:A total of 48 patients were implanted with the subacromial spacer using arthroscopic approach with or without biceps tenotomy. All patients were assessed for up to 12 months post-implantation and 18 patients were assessed for at least 24 months (and a maximum of 40 months). Improvement in shoulder function was assessed using Constant score.Results:Subacromial spacer implantation was performed arthroscopically in 48 patients. The mean total Constant score increased from 36 at baseline to 67 points at 12 months post implantation. Patients who underwent LHB tenotomy in addition to the subacromial spacer presented similar improvement of their shoulder function and score compared to the group that was treated with the spacer alone.Conclusion:Current study demonstrates that spacer implantation in this patient population provides significant improvement in function and decreases the pain. Additional LHB tenotomy did not influence the postoperative results during the follow-up.

Comparison of Outcomes 1 Year After Rotator Cuff Repair With and Without Concomitant Biceps Surgery

To compare the outcomes of patients who undergo a long head of the biceps (LHB) procedure (tenotomy or tenodesis) concomitant with rotator cuff repair (RCR) to those of patients who undergo isolated RCR. Prospectively collected data were retrospectively reviewed on 80 patients, >18years old, who underwent repair of a full-thickness rotator cuff tear and with 1-year patient-reported outcome scores collected June 2012 to March 2015. The exclusion criteria were concomitant procedures other than LHB tenotomy, tenodesis, or subacromial decompression; prior shoulder surgery; or other shoulder pathology. The 3 patient groups are as follows: RCR+ tenotomy, RCR+ tenodesis, and isolated RCR. The primary outcome measures were American Shoulder and Elbow Surgeons (ASES) score, Western Ontario Rotator Cuff (WORC) index, and visual analog scale (VAS) for pain. A t-test measured the mean improvement in LHB patients compared with isolated RCR patients and compared the LHB tenotomy and tenodesis groups. Stepwise linear progression used LHB tenotomy or tenodesis as the primary predictor. The biceps procedure group had more female patients (22 vs 7, P= .01); otherwise there were no significant baseline differences. The LHB procedure group had significantly worse baseline ASES scores (mean, 48.9 vs 58.7; P= .032). All RCR patients showed significant improvement in all 3 outcome measures. Patients who had either LHB tenotomy or tenodesis (n= 45) demonstrated significantly greater mean improvement in ASES (mean, 42.7 vs 23.8; P= .002), VAS (mean, 49.2 vs 35.7; P= .020), and WORC scores (mean, 928 vs 743; P= .029) at 1-year follow-up compared with patients who had isolated RCR. ASES scores at 1year were significantly better in the biceps group (91.6 vs 82.5; P= .023). Linear regression found a biceps procedure to be predictive of a significantly greater improvement in ASES score (P= .01). Analysis of variance revealed that both the LHB tenotomy (P= .04) and tenodesis (P= .01) groups demonstrated more favorable improvement in ASES when compared with RCR alone. Patients who underwent a concomitant biceps procedure when indicated at the time of RCR demonstrated inferior baseline patient-reported outcome measures and greater improvement after 1year, as well as more favorable ASES scores at 1year compared with isolated RCR patients. Level III, retrospective comparative study.

Long Biceps Subpectoral Tenodesis With Suspensory Button and Bicortical Fixation

Tenodesis of the long head of the biceps (LHB) tendon has long been recognized as a valid alternative to address pathologic conditions of this tendon. However, the location and type of fixation is still a matter of discussion, because common complications associated with this procedure include failure of the repair, persistent pain, reaction to the fixation device, cosmetic deformity, and fracture. The authors describe a method of subpectoral LHB tenodesis that aims to preserve bone stock and allows a strong, easy, and reproducible type of fixation with a minimal approach. LHB tenotomy is performed arthroscopically in a standard fashion, and the tenodesis is completed with bicortical fixation in the humerus using a knotless suspensory button with an appropriate pusher originally developed for another purpose. Magnetic resonance imaging showed a safe distance between the implant and important vasculonervous structures. In the cases where subpectoral fixation is chosen, this method seems to offer additional safety as a result of the minimal amount of bone removed and the very small size of the implant.

Long Head of the Biceps Tenotomy and Tenodesis: Does Technique, Location, or Implant Influence Outcomes and Complications?

Surgical treatment of long head of the biceps tendon (LHBT) lesions due to pain or structural damage (partial tear, dislocation) is controversial. Post-operative complications including cosmetic “Popeye” deformity, biceps cramping, biceps weakness, persistent anterior shoulder pain, and proximal humerus fracture have been reported with these techniques. We present the largest series of surgical LHBT procedures and analyze their complications. Records of patients who underwent a LHBT tenotomy +/- tenodesis at an integrated health care system by 84 surgeons were retrospectively analyzed. Inclusion criteria were patients who underwent a shoulder arthroscopic procedure where the LHBT was surgically released. Exclusion criteria included revision tenodesis, arthroplasty, neoplastic, or fracture surgery, age below 18, or incomplete data. Fixation methods, location of tenodesis, as well as indication for LHBT procedure (anterior shoulder pain versus structural), and post-operative complications were recorded. 1635 patients (1722 shoulders) were included. 1132 patients were male (69%). The average age was 54.5 years (range from 18-91). The average follow-up duration was 10.8 months. Biceps related complications are summarized in Table 1. 18 (1.04%) nerve injuries were encountered, which all completely resolved. Subpectoral tenodesis techniques had a significantly higher rate nerve injury (p = 0.016). One subpectoral tenodesis (0.12%) with a unicortical button and a 3.2mm tunnel suffered a proximal humerus fracture. Open and mini-open techniques demonstrate a significantly higher rate of superficial infection compared with arthroscopic techniques (2.32% versus 0.60%, p = 0.029). We present the largest study analyzing LHBT procedures. While tenotomy and tenodesis provide reliable pain relief, we found no difference in persistent post-operative anterior shoulder pain between tenotomy versus tenodesis, regardless of whether the technique left the LHBT in the groove or not. However, tenotomy had a significantly higher rate of biceps related post-operative complications compared with tenodesis. The overall nerve injuries were low and all recovered.

Platelet-rich plasma supplementation in arthroscopic repair of full-thickness rotator cuff tears: a randomized clinical trial.

Results on the effectiveness of PRP supplementation in arthroscopic rotator cuff repair are conflicting, making it difficult to draw definitive conclusions. This was a prospective, randomized, and double-blind study with two groups of 20 patients each (PRP group and control group). Degenerative supraspinatus full-thickness tears grade C2-C3 were subjected to arthroscopic repair; PRP supplementation was given to patients in the PRP group. The outcomes were assessed by DASH, Constant scales, and ultrasound before and 6months after surgery. Pain measured by VAS was evaluated preoperatively and 7 and 30days after surgery. The two groups did not differ significantly by age, sex, and dominance of the affected side. In all surgical procedures, a long head of the biceps tenotomy and single-row repair were performed. The preoperative VAS was 5.6±2.4 in PRP group and 6.4±1.5 in the control group (p>0.05). The group supplemented with PRP reported a VAS significantly better in the first week (2.5±1.9 vs 5.3±2.1, p<0.05) and during the first month after surgery (1.5±1.0 vs 3.2±1.7, p<0.05) compared to the control group. The preoperative Constant and DASH scores were 39.95±12 and 51±15.2, respectively, in the PRP group and 41±11 (p>0.05) and 45±12.6 (p>0.05) in the control group. The average Constant score improved significantly after 6months to 81±11.2 (p<0.05) in the PRP group and 78.5±9 (p<0.05) in the control group. No differences were noted between the two groups (p>0.05). The DASH score after 6months was 17.4±8 (p<0.05) for the treatment group (the PRP group) and 21±8.4 (p<0.05) for the control group. No statistically significant differences were found as regards the DASH score in the two groups after 6months (p>0.05). The two groups showed no differences in the ultrasound evaluation after 6months either. No re-ruptures occurred in either group. PRP leads to a reduction in pain during a short-term follow-up. Pain reduction allows for a more rapid recovery of mobilization and improvement in functionality. Randomized controlled trial, Level of evidence, 1.

Ultrasound-guided intra-articular tenotomy of the long head of the biceps: a cadaveric feasibility study.

Isolated tenotomy of the long head of the biceps (LHB) is known to improve function in patients with massive and non-reparable cuff tears without osteoarthritis. This two step cadaveric study was performed with the purpose to identify the best surgical technique for isolated LHB tenotomy under USG guidance (pilot study) and evaluate its feasibility (subsequent study). Pre-operative ultrasonographic evaluation of the rotator cuff was performed and any specimens whose long head of the biceps was not found to be intact during the pre-operative ultrasound evaluation were excluded. In the pilot study, nine scar-free cadaveric shoulders underwent ultrasound-guided tenotomy through a single percutaneous portal to determine the best instrument and approach which ensure elective and complete LHB tenotomy. Using it, a second series of 12 cadaveric shoulders were operated following a similar protocol to evaluate the feasibility of this technique. Pilot study: The use of a backward endoscopic cutter through a posterior percutaneous portal was found to be the safest. Control of the tenotomy was possible by manipulating the intra-articular part of the tendon with the instrument ("Groove Alone" test). Subsequent study: The tenotomy of the LHB was complete in all cases. Mean length of the proximal LHB stump was 0.3cm (range, 0-0.8cm). No iatrogenic lesion was observed when using the backward endoscopic cutter. On the other hand, the use of straight endoscopic scissors led to severe damage to the rotator cuff and the conjoined tendon. The "Groove Alone" test checked against iatrogenic injury. This was not done in one of the cases and it led to a partial section of the superior half of the tendon of the subscapularis. By the use of both appropriate endoscopic instrumentation and the newly described "Groove Alone" test, ultrasound-guided LHB tenotomy through a single percutaneous portal appears to be a feasible and reliable procedure that could be an alternative to isolated arthroscopic tenotomy. The choice of a posterior portal (soft point) may increase the safety and precision of this procedure and decrease the length of the proximal stump of the LHB.

TGF-β rescues extracellular matrix turnover in rotator cuff pathology

Introduction: Tendinopathies are the most frequent causes of chronic shoulder pain. Long head of the biceps (LHB) tendon lesions are often associated with massive rotator cuff (RC) tears. Palliative LHB tenotomy decreases RC disease patient’s pain and disability. The aim of this work was to identify the biological changes of LHB in RC disease and assess its association with clinical manifestations. Methods: RC disease patients submitted to LHB tenotomy were evaluated using a clinical protocol in order to retrieve information regarding shoulder pain duration and intensity (visual analogue scale) and shoulder function (Constant score). LHB tendon samples from these patients were compared with cadaver controls. Tendon tissue was qualitatively studied by conventional histology and immunohistochemistry was used to access semi quantitatively the presence of substance P and calcitonin gene-related peptide (CGRP). Tendon cell cultures were used to determine the gene expression of several extracellular matrix genes with and without stimulation with transforming growth factor (TGF)-β, TNF, IL-10 or dexamethasone. Results: Histologically, LHB tendon from RC patients and cadaver controls had similar characteristics. RC patients had a significantly higher CGRP immunohistochemistry score as compared to controls (p=0.010) but there was no correlation with patient clinical features. On the contrary, regarding substance P no differences were found between RC patients and controls immunohistochemistry score but a correlation with shoulder pain (r=0.828, p=0.021) was identified. Through gene expression analysis we found a downregulation of the extracellular matrix genes type I collagen and thrombospondin 4, as well as vascular endothelial growth factor (VEGF) and nerve growth factor (NGF) in Manuscript Click here to download Manuscript manuscript.docx 2 patients with RC disease. However, in vitro stimulation of RC tenocytes with TGF-β rescued their ability to produce type I collagen and VEGF. Conclusion: LHB tendon from RC disease patients had neurotransmitter disturbances that could be related to shoulder pain. Moreover, we demonstrated that LHB from RC disease patients had a downregulation of extracellular matrix genes, as well as of VEGF and NGF genes. We showed that TGF-β can partially normalize the expression of these genes, suggesting that modulating TGF-β could be a therapeutic opportunity for improving tendon quality in the context of chronic tendinopathies.

Ultrasound-guided percutaneous long head of the biceps tenotomy.

Dear Editor, We would like to discuss on the recent publication of “Ultrasound-guided percutaneous long head of the biceps tenotomy [2].” Greditzer et al. reported a case and mentioned for the usefulness of this technique. In fact, the feasibility of this technique has just been reported by Aly in J. Clin. Ultrasound [4]. Aly et al. noted that “the deep to superficial approach using an arthroscopic hook blade resulted in complete transection [4].” However, Levy et al. reported that this technique was not reliable [4]. According to the report by Levy et al. [4], “iatrogenic lesions of the cartilage of the humeral head, the supraspinatus tendon and the subscapularis tendon” are the unwanted outcome. In fact, to perform tenotomy of the long head of the biceps tendon, there are other alternatives. The good example is the arthroscopic tenotomy [5]. In addition, the outcome of any manipulation, adding to the surgical technique, also depends on “preoperative condition and coexistent subscapularis tears” [5]. Further comparative study of this new technique versus other alternative is suggested.

Reply to letter to the editor: ultrasound-guided percutaneous long head of the biceps tenotomy.

The recent publication by Aly et al. [1] further confirms our conclusion that ultrasound-guided percutaneous tenotomy of the long head of the biceps tendon is feasible. Our paper was accepted for publication in April 2014 [2], and the Aly et al. paper was accepted for publication in June 2014. Since we had no previous knowledge of their study, we could not reference it in our paper. However, they describe a similar technique and results to ours using an arthroscopic hook blade, with a deep to superficial approach in the cadavers, which successfully resulted in complete tendon transection and no evidence of iatrogenic injury. We are the first to describe this procedure successfully performed on a live subject. Both the Aly et al. and the Levy et al. [3] studies show that the use of size 11 blade scalpels, banana blades, and retractable serrated blades results in incomplete transections of the tendons, as well as iatrogenic lesions of the cartilage, supraspinatus tendon, and subscapularis tendon. This further supports our conclusion that hook blades are the ideal instruments to obtain successful results of complete tendon transection, without iatrogenic injury. We concur that future long-term comparative studies of US-guided percutaneous tenotomy procedures are necessary to determine the efficacy of the procedure.