Popeye Deformity Research Articles

Both Isolated Long Head of the Biceps Tenotomy and Tenodesis Are Effective for Symptomatic Rotator Cuff Repair Revision

Background: Symptomatic rotator cuff (RC) repair continues to be a complex issue. Leaving the long head of the biceps (LHB) in place might increase the risk of residual pain, even in the case of a healed RC. The purpose of this study was to assess the clinical outcomes of isolated LHB tenotomy and tenodesis as a revision procedure in symptomatic patients that had previously undergone an arthroscopic RC repair with no clinical or MRI evidence of RC retear. Methods: A retrospective analysis was conducted on patients with a persisting painful shoulder after an arthroscopic RC repair with no clinical or MRI signs of cuff retear, undergoing an isolated arthroscopic biceps tenotomy or tenodesis as a revision procedure. Functional outcomes were assessed preoperatively and at a minimum of 24 months of follow-up. Results: A total of 88 patients were included. The biceps tendon was managed with biceps tenodesis in 64 patients and tenotomy in 24 patients. VAS, Constant Score, SSV and active anterior elevation were all significantly improved after revision surgery. There was no significant difference between pre- and postoperative anterior passive elevation. No significant difference was shown between the tenodesis and tenotomy groups. Conclusions: The present study demonstrated that both isolated tenotomy and tenodesis are effective and safe in treating patients with a symptomatic shoulder after RC repair at a 2-year follow-up with a very low complication rate. Although tenodesis did not show any significant clinical benefit outcomes compared to tenotomy, it might be associated with a lower risk of Popeye deformity.

The Incidence of Popeye Deformity After Soft-Tissue Biceps Tenodesis Is Comparable to Biceps Anchor Tenodesis and Lower Than Biceps Tenotomy During Arthroscopic Rotator Cuff Repair.

To compare clinical and radiologic outcomes between biceps anchor tenodesis (AT), biceps soft-tissue tenodesis (ST), and biceps tenotomy (TT) for patients with concomitant rotator cuff repair (RCR). This retrospective study reviewed patients who underwent arthroscopic RCR for full-thickness rotator cuff tears with AT, ST, or TT with minimum 2-year follow-up. All biceps procedures were performed arthroscopically, and ST consisted of fixation to the transverse humeral ligament. We excluded massive rotator cuff tears, additional biceps procedures, and revisions. Patient-reported outcome measures (PROMs) (visual analog scale [VAS] pain score, VAS functional score, American Shoulder and Elbow Surgeons score, and Constant score) and elbow flexion (EF) strength were evaluated preoperatively and at final follow-up. A total of 155 patients (50 AT, 52 ST, and 53 TT patients) were included in this study. The AT group was younger (mean age, 58.7 ± 6.3 years in AT group, 67.6 ± 5.0 years in ST group, and 66.1 ± 5.3 years in TT group) and had a lower proportion of female patients (13 [26.0%] in AT group, 31 [59.6%] in ST group, 39 [73.6%] in TT group) than the ST and TT groups (all P < .001). At final follow-up, PROM scores were significantly improved in all 3 groups (all P < .001). The VAS pain score (P= .134), VAS functional score (P= .616), and American Shoulder and Elbow Surgeons score (P= .093) at final follow-up showed no significant differences between the 3 groups. The Constant score and EF strength were significantly higher in the AT group than in the ST and TT groups preoperatively (P= .009 for Constant score, P= .033 for EF strength) and at final follow-up (P<.001 for Constant score, P < .001 for EF strength). There was no significant difference in mean improvement in PROM scores and EF strength or in the proportion of achievement of the minimal clinically important difference. The incidence of Popeye deformity was significantly higher in the TT group (n= 11, 20.8%) than in the AT group (n= 3, 5.8%) and ST group (n= 4, 8.0%) (P= .035). Regression analysis showed that TT (odds ratio, 15.6; P < .001) and male sex (odds ratio, 103.9; P < .001) were associated with Popeye deformity and that ST (coefficient, -0.51; P= .035) was associated with bicipital groove pain. Biceps AT, ST, and TT during arthroscopic RCR showed good clinical outcomes. Although there was a possibility of selection bias, there was no significant difference in mean improvement in clinical outcomes between the 3 long head of the biceps tendon procedures. The incidence of Popeye deformity was higher in the TT group, and that of biceps groove pain was higher in the ST group. Level III, retrospective cohort study.

Clinical Outcomes After Mini-Open Subpectoral Biceps Tenodesis

Background Long head of the biceps tendon pathology is a common cause of shoulder pain. Current surgical treatment options for long head of the biceps tendon disorders include tenotomy and tenodesis. Younger and high-demand patients are usually treated with tenodesis since tenotomy is associated with increased biceps pain and cramping, cosmetic deformity and patient dissatisfaction. Previous studies have shown biomechanical advantages of subpectoral open approach over arthroscopic suprapectoral approach, with less biceps over tension and increased ultimate load to failure. Despite this, there is a lack of consensus in the literature regarding the management of biceps-related pathology. Methods We retrospectively reviewed all patients who underwent subpectoral biceps tenodesis with unicortical endo-button fixation between January 2015 and December 2019. Only patients who had a minimum of 24 months follow-up were included in the study. We reviewed patient demographics. The American Shoulder and Elbow Surgeons and Visual Analogue score were assessed and complications were recorded. Results A total of thirty-two patients were enrolled in this study. 15 were young patients and sports athletes with SLAP (Superior Labrum from Anterior to Posterior) lesions or isolated biceps instability and the remaining 17 were middle-age patients with degenerative biceps disease and concomitant pathology. The mean follow-up time was 36 months. SLAP lesions group average age was 24,3 and degenerative group average age was 53,8. The ASES score and the VAS score and were statically significative better in the isolated subpectoral tenodesis due to SLAP lesions 99,8 and 0,1 respectively in comparison with the degenerative group, 85,7 and 1,5 respectively. We recorded two complications. One case of superficial infection and one case of a patient that was concomitant submitted to arthroscopic rotator cuff tear repair with persisting shoulder pain. There was no case of failure of fixation or associated Popeye deformity. Conclusions Subpectoral biceps tenodesis with unicortical endo-button fixation is a viable treatment option for patients with symptomatic biceps disease. Anterior shoulder pain and biceps symptoms were resolved with this technique. Patients with coexistent rotator cuff lesion may have less favorable outcomes.

Arthroscopic Suprapectoral Biceps Tenodesis: A Knotless, Onlay, All-Suture Anchor Technique

Anterior shoulder pain is a common complaint often caused by pathology of the long head of the biceps such as biceps tendinitis, partial biceps tears, biceps instability, and SLAP lesions. Surgical treatment of biceps pathology includes tenotomy versus tenodesis, with tenodesis being favored in young, active patients owing to less cramping pain and superior outcomes in terms of shoulder function and cosmesis. Various surgical techniques for tenodesis of the long head of the biceps exist, with varying indications. Subpectoral biceps tenodesis is primarily indicated for zone 2 to 3 tendon pathology and revision biceps tenodesis. Secondary indications include overhead athletes, chronic biceps tendinopathy, and rotator cuff repair. Proximal arthroscopic biceps tenodesis performed “high in the groove” has been shown to preserve biceps length and reduce Popeye deformity compared with tenotomy. Knotless techniques are becoming popular; they provide low-profile fixation that limits knot abrasion and is not reliant on knot security for fixation. We present a variation of suprapectoral biceps tenodesis using knotless fixation in an onlay technique.

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

ObjectivesThe development of the Popeye’s deformity is a known complication of long head of bicep tendon (LHBT) tenotomy. Incidence of developing Popeye’s deformity after LHBT tenotomy ranges between 13 - 70%. While this complication is well tolerated, it can be avoided with proper patient selection. We aim to study patient and clinical factors resulting in the development of the Popeye’s deformity after LHBT tenotomy so as to better identify suitable surgical candidates. Methods91 patients underwent unilateral rotator cuff repairs and concomitant LHBT tenotomy between March 2013 and March 2017. Assessment of patient factors contributing to Popeye’s deformity included patient demographics and physical attributes were analysed and correlated. Patients also completed a questionnaire regarding their overall post-operative satisfaction. Prospectively collated Visual Analogue Pain (VAS), Constant-Murley Shoulder Score (CSS), UCLA Shoulder Score (UCLA) and Oxford Shoulder Score (OSS) were compared at 6 and 24 months post-operation between patients who developed Popeye’s deformity and those who did not. ResultsThe incidence of post-tenotomy Popeye’s sign was 58.9%. Majority of patients were satisfied with their procedure, postoperative function and cosmesis. Patients who developed Popeye’s sign had a statistically significant lower body mass index (BMI) (24.9 ± 4.2 kg/m2 versus 27.3 ± 4.3 kg/m2, p = 0.048) (rpb = - 0.210, p > 0.05) and had a greater biceps circumference (in flexion) to wrist circumference ratio (1.91 ± 0.16 versus 1.83 ± 0.13, p = 0.012) (rpb = 0.319, p < 0.05) compared to those who did not. Nevertheless, the development of Popeye’s sign did not affect clinical outcomes (VAS, CSS, UCLA and OSS, p > 0.05) at 24 months. ConclusionsThe incidence of Popeye’s deformity is high post LHBT tenotomy. There was a greater incidence in patients with lower BMI and greater biceps brachii muscle bulk. However, this complication is well tolerated. By better selecting our patients, we can achieve better outcomes and minimise potential complications. Level of evidenceLevel III Evidence. Retrospective comparative study.

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

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

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

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

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

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

An Expedited Sling Immobilization Protocol After Isolated Biceps Tenodesis Results in Clinical and Patient-Reported Postoperative Outcomes Equivalent to a Standard Rehabilitation Protocol

PurposeTo characterize clinical and patient-reported outcomes for patients after isolated biceps tenodesis (BT) who underwent either standard or expedited sling immobilization protocols following surgery. MethodsThis retrospective cohort study comparing patients who were assigned to use a sling for either four- to six-weeks (standard) or zero- to two-weeks (expedited) following an isolated BT. Primary endpoint included rate of re-rupture, surgical revision, loss of fixation, and Popeye deformity. Secondary endpoints included shoulder range of motion (ROM) as well as pre- and post-operative patient reported outcomes (PROs) of pain and function. Missing data was managed via multiple imputation with chained equations. Complication prevalence 95% confidence intervals were calculated using the Clopper Pearson method and a series of hierarchical mixed effects linear regressions were performed to assess differences between sling interventions in PROs and ROM. ResultsThe average age of the standard cohort (n=66) was 49 years ( ± 14) and the average age of the expedited cohort (n=69) was 47 years (± 14). The expedited and standardized cohorts demonstrated 0.4 and 0.3 complications per 10,000 exposure days, respectively, with no significant difference between groups [1.4 (95% CI: 0.2, 10.0), p = 0.727]. There was no demonstrated difference in forward flexion, abduction, or external range of motion. The expedited group had less improvement in Visual Analogue Scale (VAS) for pain scores that was not clinically significant and there were no differences in PROs of function. ConclusionsNo statistically significant difference in the rate of re-rupture, surgical revision, loss-of-fixation, or Popeye deformity was noted between protocols after isolated BT. Furthermore, there were no clinically significant differences in ROM or PROs identified between protocols after isolated BT. This study suggests that patients who have undergone isolated BT may safely discontinue sling use within two weeks after surgery.

Intra-articular soft arthroscopic Latarjet technique as a Bankart-plus procedure for type V superior labrum anterior-posterior lesion: lower rate of instability recurrence and better functional outcomes of a prospective cohort study.

Intra-articular soft arthroscopic Latarjet technique (in-SALT) involves augmentation of arthroscopic Bankart repair (ABR) with soft tissue tenodesis of long head of biceps to upper subscapularis. This study was conducted to investigate superiority of outcomes of in-SALT-augmented ABR over those of concurrent ABR and anterosuperior labral repair (ASL-R) in management of type V superior labrum anterior-posterior (SLAP) lesion. This prospective cohort study (conducted between January 2015 and January 2022) included 53 patients with arthroscopic diagnosis of type V SLAP lesion. Patients were allocated into 2 consecutive groups: group A of 19 patients managed with concurrent ABR/ASL-R and group B of 34 patients managed with in-SALT-augmented ABR. Outcome measurements included 2-year postoperative pain, range of motion, and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) and Rowe instability scores. Failure was defined as frank/subtle postoperative recurrence of glenohumeral instability or objective diagnosis of Popeye deformity. The statistically matched studied groups showed significant postoperative improvement in outcome measurements. However, group B demonstrated significantly better 3-month postoperative visual analog scale score (3.6 vs. 2.6, P=.006) and 24-month postoperative external rotation at 0° abduction (44° vs. 50°, P=.020) and ASES (84 vs. 92, P<.001) and Rowe (83 vs. 88, P=.032) scores. Rate of postoperative recurrence of glenohumeral instability was relatively lower in group B (10.5% vs. 2.9%, P=.290). No Popeye deformity was reported. For management of type V SLAP lesion, in-SALT-augmented ABR yielded a relatively lower rate of postoperative recurrence of glenohumeral instability and significantly better functional outcomes compared with concurrent ABR/ASL-R. However, currently reported favorable outcomes of in-SALT should be validated via further biomechanical and clinical studies.

Modified arthroscopic intra-articular transtendinous looped biceps tenodesis leads to satisfactory functional outcomes and less frequent Popeye deformity compared to biceps tenotomy

PurposeThe present study aimed to propose a modified intra-articular transtendinous looped biceps tenodesis (mTLBT) using a suture anchor and to compare the functional outcomes and incidence of Popeye deformities between biceps tenotomy and mTLBT.MethodsMedical records of patients who underwent either tenotomy or mTLBT for the long head of the biceps tendon (LHBT) lesion between January 2016 and April 2021 were retrospectively reviewed. The inclusion criteria were patients aged 40–70 years with LHBT pathologies, such as superior labrum anterior to posterior (SLAP) lesions > type II, LHBT pulley system rupture with bicipital instability, and intra-articular LHBT tear. The exclusion criteria were full-thickness supraspinatus tears, frozen shoulder, shoulder fracture, and postoperative traumatic events that affected the operated shoulder. All patients were followed up for at least 1 year. Popeye deformity, bicipital cramping pain, visual analog scale (VAS) pain score, and functional outcome scores (University of California at Los Angeles [UCLA] and American Shoulder and Elbow Surgeons [ASES] scores) were recorded. Fisher’s exact test and Chi-square test were used for categorical variables, whereas the Mann–Whitney U test was used for nonparametric variables.ResultsThe mTLBT and tenotomy groups included 15 and 40 patients, respectively. The incidence of Popeye deformity and biceps cramping pain in the tenotomy group (52.5% and 50%, respectively) was significantly higher than that in the mTLBT group (13.3% and 20%, respectively) (p = 0.009 and p = 0.045, respectively). The postoperative VAS, UCLA, and ASES scores were not significantly different between the two groups. One patient in the tenodesis group experienced metallic-anchor pullout.ConclusionmTLBT is an arthroscopic intra-articular top of the groove tenodesis that can be performed completely in the intra-articular space and is especially suitable for patients with an intact or partially torn rotator cuff. This technique is reliable for treating biceps pathologies as it results in similar functional outcome scores, lesser biceps cramping pain, and less frequent Popeye deformity compared to biceps tenotomy.Level of EvidenceIII.

Arthroscopic suprapectoral biceps tenodesis provided earlier shoulder function restoration compared with open subpectoral biceps tenodesis during the recovery phase

This study compared the clinical outcomes of open subpectoral biceps tenodesis and arthroscopic suprapectoral biceps tenodesis for symptomatic biceps tenosynovitis. Although both techniques have pros and cons, no studies have compared clinical and functional outcomes during the recovery phase. Previous studies show that suprapectoral tenodesis has a higher probability of Popeye deformity and postoperative bicipital pain and stiffness, whereas subpectoral tenodesis has a higher risk of nerve complications and wound infections. This study aimed for clinical comparison between arthroscopic suprapectoral biceps tenodesis and open subpectoral biceps tenodesis. This study is a retrospective review of institutional records of patients with biceps tendinitis who underwent open or arthroscopic biceps tenodesis. Surgical indications included biceps tenosynovitis, biceps partial tear, and biceps pulley lesion. Patients with prior shoulder surgery, preoperative shoulder stiffness, or full-thickness tear of rotator cuff were excluded. Tenodesis was considered when the pain recurs within 3 months despite conservative treatment including at least 2 triamcinolone injections on the biceps tendon sheath. Visual analog scale (VAS) score for pain, presence of the night pain, American Shoulder and Elbow Surgeons (ASES) score, Constant score, and range of motion were assessed preoperatively at 3, 6, 12, and 24 months postoperatively and the last follow-up. A total of 72 patients (33 with arthroscopic suprapectoral biceps tenodeses and 39 with open subpectoral biceps tenodeses) were included in analysis. At postoperative 6 months, lower VAS score (0.4±0.8 vs. 1.7±1.9, P<.001), and the presence of the night pain (2 [6%] vs. 14 [36%], P=.002), ASES score (89.6±9.2 vs. 81.4±14.6, P=.006), and Constant score (89.4±5.6 vs. 82.0±12.5, P=.003) compared with the subpectoral group. The mean number of postoperative steroid injections for pain control in the subpectoral group (0.51±0.80) was significantly higher than that in the suprapectoral group (0.18±0.40) (P=.031). However, postoperative clinical outcomes were restored similar between the 2 groups at 12 months and the last follow-up. Arthroscopic suprapectoral biceps tenodesis performed statistically better than the subpectoral biceps tenodesis for the VAS, ASES, night pain, and Constant score at postoperative 6 months. However, only night pain and the Constant score showed differences that exceeded minimum clinically important difference during the recovery phase. At postoperative 12 and 24 months, biceps tenodesis provided satisfactory clinical outcomes and pain relief regardless of the fixation technique and suture anchor location.

A Radiostereometric Analysis of Tendon Migration After Arthroscopic and Mini-Open Biceps Tenodesis: Interference Screw Versus Single Suture Anchor Fixation.

Studies suggest that similar clinical results are achieved via arthroscopic and open biceps tenodesis (BT) techniques. To quantify the postoperative migration of the BT construct between arthroscopic suprapectoral BT (ASPBT) and open subpectoral BT (OSPBT) techniques via interference screw (IS) or single-suture suture anchor (SSSA) fixation using radiostereometric analysis. Cohort study; Level of evidence, 2. Distal migration of the biceps tendon after OSPBT with a polyetheretherketone IS, OSPBT with 1 SSSA, ASPBT with polyetheretherketone IS, and ASPBT with 2 SSSAs was measured prospectively. Patients with symptomatic biceps tendinopathy and preoperative patient-reported outcome measures (PROMs) including Constant-Murley subjective, Single Assessment Numeric Evaluation, or Patient-Reported Outcomes Measurement Information System-Upper Extremity scores were included. A tantalum bead was sutured on the proximal end of the long head of the biceps tendon before fixation of tendon tissue. Anteroposterior radiographs were performed immediately postoperatively, at 1 week, and at 3 months. Bead migration was measured, and preoperative PROMs were compared with those at latest follow-up. Of 115 patients, 94 (82%) were available for final follow-up. IS fixation yielded the least tendon migration with no difference between the open and arthroscopic approaches (4.31 vs 5.04 mm; P = .70). Fixation with 1 suture anchor demonstrated significantly greater migration than that achieved with an IS at both 1 week (6.47 vs 0.1 mm, 6.47 vs 1.75 mm, P < .001;) and 3 months (14.76 vs 4.31 mm, 14.76 vs 5.04 mm, P < .001) postoperatively. Two-suture anchor fixation yielded significantly greater migration than IS fixation at 1 week (7.02 vs 0.1 mm, P < .001; 7.02 vs 1.75 mm, P = .003) but not 3 months postoperatively (8.06 vs 4.31 mm, P = .10; 8.06 vs 5.04 mm, P = .07). Four patients with suture anchor fixation (3 patients in the OSPBT 1 SSSA group, 9.4%, and 1 patient in the ASPBT 2 SSSAs group, 3.8%) developed a Popeye deformity, whereas no Popeye deformities occurred in the IS groups. Mean 3-month bead migration in patients with and without a Popeye deformity was 60.8 and 11.2 mm, respectively (P < .0001). PROMs did not differ among groups at final follow-up. Interference screw fixation yielded the least tendon migration whether achieved arthroscopically or open. The available data indicated that fixation with 1 SSSA but not 2 SSSAs resulted in significantly greater migration than that achieved with an IS. Despite variations in tendon migration, PROMs were similar among all groups. When SSSAs are used, tendon migration may be minimized by using ≥2 anchors.

Novel all-arthroscopic biceps tenodesis technique incorporated into rotator cuff repair—two hundred cases with minimum 2-year follow-up

Biceps tendon pathology is a common source of pain in the shoulder. It is frequently seen in conjunction with symptomatic rotator cuff tears. Biceps tendon management during arthroscopic rotator cuff repairs can be achieved via tenodesis with various techniques or tenotomy. Tenodesis of the biceps generally results in less deformity and reduced exertion-related cramping. However, most techniques require the addition of some type of hardware to provide fixation for the biceps tendon, which adds cost, time, and complexity. This study presents a technique for an all-arthroscopic bicep tenodesis performed in conjunction with a double-row rotator cuff repair, requiring no additional hardware. This study is a retrospective review of data that were prospectively collected for 200 consecutive patients for whom the procedure was performed. Patients were seen postoperatively at 2 weeks, 6 weeks, 4 months, and 6 months and in addition massive rotator cuff repairs were seen at 8 months. Additionally all patients were contacted at a minimum 2-year follow-up to access for the presence deformity, the American Shoulder and Elbow Surgeons (ASES) score, and SANE score. Descriptive statistics and comparisons to known minimal clinical important differences (MCIDs) for the patient recorded outcome measures were recorded. Two hundred patients were included in the study and 152 responded to the telephone interviews. The mean age of the patients at the time of surgery was 65.3 year old (standard deviation ± 9.1, range of 46-84), and the mean postoperative phone interview was 3.2 years postsurgery (standard deviation of ± 1.0, range of 2-5 years). The average ASES score improved from 52.6 to 94.6, which is 3 times greater than the minimal clinical important difference. The average postoperative SANE score was 94. Seven procedures out of the 200 were labeled as failures due to 1 patient's nonsatisfaction with the procedure and 3 for a Popeye deformity and 3 that had a revision RCR. The described method of an arthroscopic biceps tenodesis performed with a rotator cuff repair uses no extra hardware, requires minimal additional operative time, and is clinically effective. At a minimum 2-year follow-up, the all-arthroscopic biceps tenodesis in conjunction with a double-row rotator cuff repair resulted in a marked improvement in their ASES score with a 3.5% failure rate. The all-arthroscopic bicep tenodesis performed in conjunction with a double-row rotator cuff repair demonstrated improved clinical outcome, without requiring any additional hardware to tenodese the biceps, at a minimum 2-year follow-up.

Paper 51: A Radiostereometric Analysis of Tendon Migration following Arthroscopic and Mini-Open Biceps Tenodesis: Interference Screw confers Greater Construct Stability than All-Suture Suture Anchor Fixation, with No Difference in Patient-Reported Outcomes

Objectives: To quantify the postoperative migration of the BT construct between arthroscopic suprapectoral (ASPBT) and open subpectoral (OSPBT) techniques via interference screw (IS) or all-suture anchor with a single suture (SSSA) fixation with radiostereometric analysis (RSA). Methods: Distal migration of the biceps tendon following OSPBT with a Polyetheretherketone (PEEK) IS, OSPBT with one SSSA, ASPBT with PEEK IS, and ASPBT with two SSSAs was measured prospectively. Patients with symptomatic biceps tendinopathy and preoperative Patient-Reported Outcome Measures (PROMs) including CMS, SANE, or PROMIS-UE scores were included. A tantalum bead was sutured on the proximal end of the long head biceps tendon before fixation. AP radiographs were performed immediately postoperatively, 1 week, and 3 months. Bead migration was measured, and PROMs were compared. Results: Of 115 patients, 94 were available for final follow-up (82%). Average age was 52.1±10.5 years, and BMI was 30.8±5.4 kg/m2. There was no difference in tendon migration between OSPBT and ASPBT performed with an IS (P=0.70). OSPBT performed with one SSSA (21.70 mm) demonstrated significantly greater migration than ASPBT with IS (4.31mm, P&lt;0.001) and OSPBT with IS (5.04 mm, P&lt;0.001). Three patients (9.4%) who had OSPBT with one SSSA and one who had ASPBT with two SSSAs (3.8%), developed a Popeye deformity; none occurred in the IS groups. Mean 12-week bead migration in patients with versus without Popeye deformity was 60.8 mm and 11.2 mm, respectively (P&lt;0.0001). PROMs did not differ at final follow-up. Conclusions: ASPBT and OSPBT with IS fixation demonstrated the least tendon migration, while OSPBT with one SSSA yielded the most. Compared to IS, fixation with one, but not two, SSSAs resulted in significantly greater migration. Average bead migration following a Popeye deformity was 6.1cm. To minimize migration when using SSSAs, at least 2 sutures should be used with an interlocking pattern within the tendon. [Table: see text]

Does the timing of tenotomy during biceps tenodesis affect the incidence of Popeye deformity and clinical outcome? An analysis of short-term follow-up of 2 techniques.

There are multiple techniques that attempt to maintain anatomic length-tension relationship during biceps tenodesis. However, no direct comparison has been performed with respect to the timing of biceps tenotomy during biceps tenodesis. This study aims to assess the incidence of Popeye deformity and clinical outcomes of 2 all-arthroscopic techniques for biceps tenodesis based on timing of the biceps tenotomy. A consecutive series of patients undergoing arthroscopic biceps tenodesis with concomitant rotator cuff tears were enrolled from 2019 to 2021. Biceps tenodesis performed after tenotomy formed the first cohort (group 1). The other cohort had biceps tenodesis performed prior to biceps tenotomy (group 2). Postoperative anterior arm pain, biceps muscle spasms, and patient perceptions of the appearance of the bicep muscle were assessed. In addition, patient-reported outcomes (PROs) were collected at 3 months and minimum 6 months postoperatively. A total of 71 patients were eligible for participation and 62 patients (53% female, age 58.7±9.0 years) were enrolled (n=33 in group 1, and n=29 in group 2). There were no differences between groups with respect to gender, age, and laterality of biceps tenodesis, as well as type and size of rotator cuff repair. At 3-month follow-up, Veterans RAND 12-Item Health Survey (VR-12) physical health summary scores were significantly improved in group 2 (44.8±9.7) compared with group 1 (34.1±3.4) (P=.03). In addition, patients in group 2 experienced significantly less pain in their anterior arm than patients in group 1 (19% vs. 33%, P=.02). There were no differences in biceps muscle spasm (3.4% vs. 5.2%, P=.21) and no other differences in PROs between groups. Final follow-up averaged 11.6±3.3 months in group 1 and 11.8±5.5 months in group 2. There were no significant differences in patient-perceived biceps Popeye deformity between group 1 (12.1%) and group 2 (0%) (P=.652). Furthermore, there were no differences in American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, EuroQol-5 Dimension, Patient-Reported Outcomes Measurement Information System Global Health (PROMIS 10) physical health, PROMIS 10 depression, VR-12 physical health summary, and Single Assessment Numeric Evaluation scores between the 2 technique groups. Patients with tenotomy performed after tenodesis had better VR-12 physical health summary scores and less arm pain than patients with tenotomy performed before tenodesis at 3-month follow-up. However, there were no differences in any outcome at final follow-up of nearly 1-year. In addition, there were no differences in perceived Popeye deformity between groups at any time period.

CLINICAL EFFECTIVENESS OF TENOTOMY VERSUS TENODESIS FOR LONG HEAD OF BICEPS TENDON PATHOLOGY: A SYSTEMATIC REVIEW AND META-ANALYSIS

There remains much debate regarding the optimal method for surgical management of patients with long head of biceps pathology. The aim of this study was to compare the outcomes of tenotomy versus tenodesis.This systematic review and meta-analysis was registered on PROSPERO (ref: CRD42020198658). Electronic databases searched included EMBASE, Medline, PsycINFO, and Cochrane Library. Randomized controlled trials (RCTs) comparing tenotomy versus tenodesis were included. Risk of bias within studies was assessed using the Cochrane risk of bias v2.0 tool and the Jadad score. The primary outcome included patient reported functional outcome measures pooled using standardized mean difference (SMD) and a random effects model. Secondary outcome measures included pain (visual analogue scale VAS), rate of Popeye deformity, and operative time.860 patients from 11 RCTs (426 tenotomy vs 434 tenodesis) were included in the meta-analysis. Pooled analysis of all PROMs data demonstrated comparable outcomes between tenotomy vs tenodesis (SMD 0.14, 95% CI −0.04 to 0.32; p=0.13). Sensitivity analysis comparing RCTs involving patients with and without an intact rotator cuff did not change the primary outcome. There was no significant difference for pain (VAS). Tenodesis resulted in a lower rate of Popeye deformity (OR 0.29, 95% CI 0.19 to 0.45, p &lt; 0.00001). Tenotomy demonstrated a shorter operative time (MD 15.21, 95% CI 1.06 to 29.36, p &lt; 0.00001).Aside from a lower rate of cosmetic deformity, tenodesis yielded no measurable significant benefit to tenotomy for addressing pathology in the long head of biceps. A large multi-centre clinical effectiveness randomised controlled trial is needed to provide clarity in this area.

Evaluating clinical outcomes of two biceps tenodesis techniques: Loop ‘N’ Tack and subpectoral biceps tenodesis

Biceps tenodesis is an effective surgical procedure that can address pathologies of the long head of the biceps tendon. The purpose of this study was to evaluate clinical outcomes following two different biceps tenodesis techniques: Loop 'N' Tack biceps tenodesis and subpectoral biceps tenodesis. Patients undergoing both the subpectoral biceps tenodesis and Loop 'N' Tack biceps tenodesis will have improvements in patient-reported outcomes. Hundred and sixty five consecutive patients who underwent biceps tenodesis were retrospectively identified and contacted by phone to collect visual analog scale pain scores, University of California, Los Angeles shoulder scores, Simple Shoulder Test scores, Single Assessment Numeric Evaluation scores, and American Shoulder and Elbow Surgeons scores. Range of motion, elbow flexion strength, and incidence of bicipital groove pain and Popeye deformity were recorded. One Hundred and forty five patients were included in the study (55 subpectoral, 90 Loop 'N' Tack). Patients in both groups reported high American Shoulder and Elbow Surgeons, Simple Shoulder Test, University of California, Los Angeles, Single Assessment Numeric Evaluation shoulder function scores, low visual analog scale pain scores, and had a minimal risk of complications when measured one year postoperatively. Loop 'N' Tack biceps tenodesis and subpectoral biceps tenodesis techniques are reliable and effective procedures that can reduce pain scores and restore shoulder function when patients require surgical intervention.

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

BackgroundThis review aimed to explore the available literature to update our understanding of the long head of biceps (LHB) at the shoulder. Synthesise our findings to identify emergent themes and knowledge gaps to inform future research and management directions.MethodsPubMed, Embase, Cinahl, SportDiscus, CENTRAL, and Web of Science were searched from inception to 31st December 2021. Articles were included if they referenced adult participants > 18 years of age and were written in English.Results214 articles were included in the final analysis, and results were categorised into six emergent themes: (1) Anatomy - Normal anatomical variation of the biceps from aberrant origins, third and fourth accessory heads, and an absence of the LHB tendon (LHBT) are not necessarily benign, with shoulder pain and instability a commonly reported theme. (2) Function - Bicep’s role in glenohumeral elevation and stability in healthy shoulders is minimal. In contrast, LHB has a more significant role in shoulder stability and humeral head depression in subjects with rotator cuff failure or an absent LHBT. (3) Pathology - There is an association between LHB tendinopathy, rotator cuff disease, LHBT instability and occult rotator cuff tears. Early recruitment and hyperactivity of the LHB in subjects with symptomatic rotator cuff tears and instability suggest a potential compensatory role. (4) Assessment - The limited diagnostic utility of special orthopaedic tests in assessing LHBT pathology was a consistent theme. The utility of magnetic resonance imaging and ultrasound to identify full-thickness tendon tears and instability of the LHBT was moderate to high. However, the utility of clinical tests and imaging may be underestimated due to arthroscopy’s limitations in fully visualising the proximal LHBT. (5) Non-Surgical Management - Ultrasound-guided injections into the biceps sheath show greater accuracy and patient outcomes than blinded injections; however, the entry of injectate into the intraarticular glenohumeral joint may have unwanted complications. (6) Surgical management - For the surgical management of biceps pathology with or without rotator cuff pathology, both biceps tenodesis and tenotomy report similar improvements in pain without any significant adverse effect on strength or function. Tenodesis favoured higher overall constant scores and a lower incidence of Popeye deformity and cramping arm pain, with tenotomy trending to be more cost and time effective. For patients with a healthy LHBT, rotator cuff repair with adjunctive tenodesis or tenotomy fails to provide additional clinical improvements compared to rotator cuff repair in isolation.ConclusionsThe scoping review highlights the variability of biceps anatomy, which is not necessarily benign and suggests a minimal role of the LHB in shoulder elevation and stability in healthy individuals. In contrast, individuals with rotator cuff tears experience proximal humeral migration and demonstrate hyperactivity of the LHB, suggesting a potential compensation role. The observed prevalence of LHBT pathology with rotator cuff tears is well established; however, the cause-and-effect relationship between LHBT pathology and rotator cuff disease is undetermined. The diagnostic utility of clinical tests and imaging to exclude LHBT pathology may be understated due to the limitations of arthroscopy to visualise the proximal LHBT fully. Rehabilitation programs for the LHB are understudied. Similar post-surgical clinical outcomes are observed for tenodesis and tenotomy for biceps and rotator cuff-related shoulder pain. Subjects undergoing biceps tenodesis are less likely to have cramping arm pain and a Popeye deformity than patients undergoing biceps tenotomy. The significance of routine surgical removal of the LHBT and sequelae on rotator cuff tear progression to failure and long-term shoulder function is unknown, and further research is required.Pre-registrationOSF: https://osf.io/erh9m

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

Surgical options for long head of the biceps tendon (LHBT) lesions include tenotomy and tenodesis. This study aims to determine the optimal surgical strategy for LHBT lesions with updated evidence from randomised controlled trials (RCTs). Literature was retrieved from PubMed, Cochrane Library, Embase and Web of Science on 12 January 2022. Randomised controlled trials (RCTs) comparing the clinical outcomes of tenotomy and tenodesis were pooled in the meta-analyses. Ten RCTs with 787 cases met the inclusion criteria, and were included in the meta-analysis. Constant scores (MD, -1.24; p = 0.001), improvement of Constant scores (MD, -1.54; p = 0.04), Simple Shoulder Test (SST) scores (MD, -0.73; p = 0.03) and improvement of SST (p < 0.05) were significantly better in patients with tenodesis. Tenotomy was associated with higher rates of Popeye deformity (OR, 3.34; p < 0.001) and cramping pain (OR, 3.36; p = 0.008]. No significant differences were noticed between tenotomy and tenodesis regarding pain (p = 0.59), American Shoulder and Elbow Surgeons (ASES) score (p = 0.42) and its improvement (p = 0.91), elbow flexion strength (p = 0.38), forearm supination strength (p = 0.68) and range of motion of shoulder external rotation (p = 0.62). Subgroup analyses showed higher Constant scores in all tenodesis types and significantly larger improvement of Constant scores regarding intracuff tenodesis (MD, -5.87; p = 0.001). According to the analyses of RCTs, tenodesis better improves shoulder function in terms of Constant scores and SST scores, and reduces the risk of Popeye deformity and cramping bicipital pain. Intracuff tenodesis might offer the best shoulder function as measured with Constant scores. However, tenotomy and tenodesis provide similar satisfactory results for pain relief, ASES score, biceps strength and shoulder range of motion.