Posterolateral dislocation and incarceration of the long head of the biceps tendon: a rare cause of irreducible anterior glenohumeral joint dislocation-a case report and brief review of the literature.

Failure of closed reduction of anterior glenohumeral joint dislocation is infrequent. It can be secondary to osseous (e.g., fracture fragments or Hill-Sachs lesion) or soft tissue (e.g., labrum or rotator cuff tendon) impediments. Herein, we present a case of a prolonged irreducible glenohumeral joint secondary to a posterolaterally dislocated and incarcerated long head of the biceps tendon after an episode of anterior instability, highlight the utility of MR imaging for guiding management, and review the literature of this sporadic diagnosis.

Shear wave elastography correlates to degeneration and stiffness of the long head of the biceps tendon in patients undergoing tenodesis with arthroscopic shoulder surgery.

BACKGROUND: Tendinopathy of the long head of the biceps (LHB) tendon causes degeneration and changes its stiffness. However, a reliable means of diagnosis has not been established. Shear wave elastography (SWE) provides quantitative tissue elasticity measurements. In this study, the relationship of preoperative SWE values with biomechanically measured stiffness and degeneration of the LHB tendon tissue was investigated. METHODS: LHB tendons were obtained from 18 patients who underwent arthroscopic tenodesis. SWE values were measured preoperatively at 2 sites, proximal to and within the bicipital groove of the LHB tendon. The LHB tendons were detached immediately proximal to the fixed sites and at their superior labrum insertion. Tissue degeneration was histologically quantified using the modified Bonar score. Tendon stiffness was determined using a tensile testing machine. RESULTS: The SWE values of the LHB tendon were 502.1 ± 113.6 kPa proximal to the groove and 439.4 ± 123.3 kPa within the groove. The stiffness was 39.3 ± 19.2 N/mm. The SWE values displayed a moderate positive correlation with the stiffness proximal to the groove (r = 0.80) and within it (r = 0.72). The SWE value of the LHB tendon within the groove showed a moderate negative correlation with the modified Bonar score (r = -0.74). CONCLUSIONS: These findings suggest that preoperative SWE values of the LHB tendon correlate moderately positively with stiffness and moderately negatively with tissue degeneration. Therefore, SWE may predict LHB tendon tissue degeneration and changes in stiffness caused by tendinopathy.

Long Head of the Biceps Tendon Plays a Role in Stress Absorption and Humeral Head Restriction during the Late Cocking and Deceleration Phases of Overhead Throwing: A Finite Element Study.

BACKGROUND: Emerging evidence suggests that the long head of the biceps (LHBT) may play a role in stabilizing the glenohumeral joint, and this has led to controversy around the efficacy of biceps tenotomy for superior labral anterior and posterior (SLAP) lesions. Therefore, the aim of this finite element analysis (FEA) study was to determine the stress absorption and humeral head translation restriction effects of the LHBT within the glenohumeral joint during the late cocking and deceleration phases of overhead throwing with a view to resolving the controversy around tenotomy. METHODS: Eight FEA models were created using computed tomography and magnetic resonance imaging data from normal glenohumeral joints. The models represented four LHBT conditions: uninjured, subpectoral tenodesis, tenotomy, and type II SLAP lesions. The late cocking and deceleration phases of the overhead throwing were simulated for each model. The impacts of the four LHBT conditions on glenohumeral joint stress absorption and humeral head displacement restriction were studied based on 1) stress and related distributions on the cartilage, labrum, capsule, and LHBT and 2) humeral head translation variation. RESULTS: The FEA analysis showed that the magnitude of the contact stress on the articular cartilage, labrum, and capsule was the lowest in the uninjured models, followed by the subpectoral tenodesis, tenotomy, and type II SLAP lesion models. Humeral head translation was the most restricted in the subpectoral tenodesis models, followed by the tenotomy and type II SLAP lesion models. CONCLUSION: Finite element analysis demonstrated that the LHBT plays a significant role in stress absorption and displacement restriction in the late cocking and deceleration phases of overhead throwing. Subpectoral tenodesis of the LHBT exhibited lesser amount of stress and humeral head translation than those of tenotomy, thereby making it a better option for patients who engage in overhead throwing.

Long head of biceps tendon autograft is effective in the management of large to massive rotator cuff tear: a systematic review.

PURPOSE: The aim of this systematic review is to review the functional, clinical and radiological outcomes of patients undergoing large to massive rotator cuff repair with long head of biceps tendon (LHBT) autograft, as well as compare these to standard arthroscopic cuff repair. METHODS: A review of the online Medline database was conducted on 20 October 2022 according to PRISMA guidelines and registered prospectively on the PROSPERO database. Clinical studies assessing patients with large to massive rotator cuff tears undergoing LHBT autograft repair were included. All studies reported on functional outcomes, range of movement (ROM) and radiological re-tear rates. The Methodological Index for Non-Randomised Studies (MINORS) tool was used to appraise all studies. RESULTS: The search strategy identified ten studies for inclusion including a total of 594 patients. Five studies were comparable (346 patients), assessing LHBT autograft repair against arthroscopic rotator cuff repair without autograft. A variety of techniques of LHBT autograft were used across all studies, including bridging and augmentation styles. Radiographic comparison showed lower re-tear rates in the LHBT autograft group with two studies demonstrating statistically significant results. Pain scores, functional outcomes and ROM were significantly improved post-operatively in all studies for LHBT autograft patients, with no significant difference when compared to standard arthroscopic repair. CONCLUSION: LHBT autograft looks to significantly improve functional scoring and range of motion in patients with large to massive rotator cuff tears. When compared to standard arthroscopic cuff repair, LHBT autograft appears to significantly reduce the re-tear rate. Further randomised studies are needed to assess the efficacy of this technique.

A preliminary attempt to use radiomic features in the diagnosis of extra-articular long head biceps tendinitis.

BACKGROUND: This study aims to present a radiomic application in diagnosing the long head of biceps (LHB) tendinitis. Moreover, we evaluated whether machine learning-derived radiomic features recognize LHB tendinitis. PATIENTS AND METHODS: A total of 170 patients were reviewed. All LHB tendinitis patients were diagnosed under arthroscopy. Radiomic features were extracted from preoperative magnetic resonance imaging (MRI), and the input dataset was divided into a training set and a test set. For feature selection, the t test and least absolute shrinkage and selection operator (LASSO) methods were used, and random forest (RF) and support vector machine (SVM) were used as machine learning classifiers. The sensitivity, specificity, accuracy, and area under the curve (AUC) of each model's receiver operating characteristic (ROC) curves were calculated to evaluate model performance. RESULTS: In total, 851 radiomic features were extracted, with 109 radiomic features extracted using a t test and 20 radiomic features extracted using the LASSO method. The random forest classifier shows the highest sensitivity, specificity, accuracy, and AUC (0.52, 0.92, 0.73, and 0.72). CONCLUSION: The classifier contract by 20 radiomic features demonstrated a good ability to predict extra-articular LHB tendinitis.However because of poor segmentation reliability, the value of Radiomic in LHB tendinitis still needs to be further explored.

Three-dimensional SPACE MR with CAIPIRINHA fourfold acceleration for assessing long head of biceps tendon.

BACKGROUND: Data regarding controlled aliasing in parallel imaging results in higher acceleration (CAIPIRINHA) T2-weighted sampling perfection with application optimized contrast evolution (SPACE) with fourfold acceleration factor for assessing long head of biceps tendon (LHBT) disorder is lacking. PURPOSE: To investigate the feasibility of 3D CAIPIRINHA SPACE with fourfold acceleration in assessing LHBT disorder. MATERIAL AND METHODS: A total of 42 consecutive patients underwent shoulder magnetic resonance (MR) examinations including CAIPIRINHA SPACE with fourfold acceleration, and non-CAIPIRINHA SPACE with twofold acceleration, and 2D fast spin echo (FSE). A subjective score of depiction of LHBT was given to 3D sequence according to a 4-point scale (0-3, "poor" to "excellent"). The Wilcoxon signed rank test was used to compare depiction scores between 3D sequences. Three statuses of LHBT were defined in the study: normal, tendonitis, and tear. McNemar's test was used compare diagnostic accuracy. RESULTS: LHBT was better depicted with CAIPIRINHA SPACE versus non-CAIPIRINHA SPACE (2.1 ± 0.4 vs. 1.5 ± 0.4; P < 0.001). Inter-modality agreement between CAIPIRINHA SPACE and 2D FSE was almost perfect (kappa = 0.884 ± 0.064). The sensitivity and specificity in detecting LHBT disorder were 95% (20/21) and 95% (20/21), respectively, for CAIPIRINHA SPACE, and 71% (15/21) and 76% (16/21), respectively, for non-CAIPIRINHA SPACE (P = 0.039). CONCLUSION: Fourfold acceleration CAIPIRINHA is feasible in reducing the acquisition time of SPACE MR in the shoulder. 3D CAIPIRINHA SPACE with fourfold acceleration is highly accurate in detecting LHBT disorder.

Imaging and histological evaluation of the long head of the biceps tendon in the presence of different types of rotator cuff tears.

BACKGROUND: A comparison of changes in the long head of the biceps tendon for different types of rotator cuff tears has not been previously performed. Furthermore, the correlation between the thickening and degeneration of the long head of the biceps tendon and the cause of these changes have not been fully clarified. We evaluated the relationship between degenerative changes in the long head of the biceps tendon and rotator cuff tears in a rat model using imaging and histology. METHODS: Ninety-six 12-week-old Sprague-Dawley rats were divided into anterior (subscapularis tear), anterosuperior (subscapularis, supraspinatus, and infraspinatus tears), superior (supraspinatus and infraspinatus tears), and control groups. The long head of the biceps tendon was harvested at 4 or 12 weeks postoperatively. The cross-sectional areas of the intra- and extra-capsular components of the tendon were measured using micro-computed tomography, and the affected/normal ratio of the cross-sectional area was calculated. Masson's trichrome staining and Alcian blue staining were performed for histologic analysis, with degenerative changes described using the modified Bonar scale. The correlation between the affected/normal ratio and Bonar scores was evaluated. RESULTS: The affected/normal ratio was higher for the anterior and anterosuperior groups than for the control group at 4 and 12 weeks. The ratio increased for the intra-articular portion in the superior group and for both the intra- and extra-articular portions in the anterior and anterosuperior groups. Degeneration considerably progressed in the anterior and anterosuperior groups compared with the control group from weeks 4 to 12 and was greater in the intra- than in the extra-articular portion. The ratio correlated with extracellular matrix score. CONCLUSIONS: Subscapularis tears were associated with progressive thickening and degeneration of the long head of the biceps tendon at 4 and 12 weeks postoperatively, which was more significant in the intra- than in the extra-articular portion. Histologic evaluation indicated that the extracellular matrix likely caused these degenerative changes.

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.

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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.

Histopathology of long head of biceps tendon removed during tenodesis demonstrates degenerative histopathology and not inflammatory changes.

BACKGROUND: The aim of this study is to describe and quantitatively analyze the histopathology of proximal long head biceps (LHB) tendinopathy in patients who have undergone LHB tenodesis. The hypothesis is that severe histopathologic changes of the LHB tendon (LHBT) will most likely be reflected with improved postoperative clinical outcomes. METHODS: The study included patients with isolated LHB tendinopathy or LHB tendinopathy associated with concomitant shoulder pathologies. All had failed conservative treatment (12 months) and had a positive pain response (> 50% reduction) pre-operatively after LHB tendon injection with local anesthetic. All underwent biceps tenodesis procedure between 2008 and 2014. Tendon specimens were collected and histologically analyzed with the semi-quantitative Bonar scoring system. Minimum follow-up time was 1 year. A subset of patients was retrospectively reviewed postoperatively and evaluated employing visual analogue score (VAS), short form survey (SF-12), American Shoulder and Elbow Surgeon (ASES) score, Disability of Arm, Shoulder and Hand (DASH) score, and Oxford Shoulder Score (OSS) and postoperative return to work status. RESULTS: Forty-five biceps tendon specimens were obtained from 44 patients (mean age 50 ± 9.6 years). Histopathological analyses demonstrated advanced degenerative changes with myxoid degeneration and marked collagen disorganization. Minimal inflammation was identified. There were no regional differences in histopathological changes. Clinical outcomes did not correlate significantly with severity of histopathologic changes. CONCLUSIONS: This study confirms that LHBT specimens in patients undergoing tenodesis demonstrate with the use of the Bonar score histopathologic changes of chronic degeneration and not inflammation. The correct histopathologic terminology for this process is LHB tendinosis. The histopathological changes appear uniform throughout the entire length of the LHBT which may inform the nature of the procedure performed.

Measurement of biceps tendon retraction after arthroscopic tenotomy.

BACKGROUND: One of the treatment options for long head of the biceps tendon (LHBT) pathology is tenotomy. To our knowledge, no study in the literature has evaluated the degree of retraction after tenotomy. The goals of this study were to determine the distance of this retraction and to identify its relationship with patient characteristics. METHODS: We conducted an observational prospective survey over a 3-month period among 30 patients operated on arthroscopically by the same surgeon between August 2018 and April 2019. A radiopaque device was introduced inside the LHBT before tenotomy. Radiographs were obtained to evaluate the distance of retraction on day 1, day 30, and day 90. RESULTS: Thirty patients were included, of whom 63.3% (19) were women. Surgery was performed for a rotator cuff tear in 10 patients (33.3%) and for subacromial impingement in the remainder of patients (66.7%) after failure of conservative management. The mean retraction of the LHBT (distance between the glenoid and clip) increased from 1.9 cm (day 1) to 3.5 cm (day 90). Three radiographic measurements were performed, and all 3 showed significant increases from day 1 to day 90. According to the Student t test, the mean retraction in the subacromial impingement group was significantly higher than that in the rotator cuff tear group on day 1, day 30, and day 90. Body mass index, younger age, sex, and dominant hand did not show any relation with LHBT retraction (P > .05). The mean LHBT retraction was significantly higher on day 90 in patients presenting with a positive Popeye sign (P < .05). CONCLUSION: At 3 months of follow-up, the mean LHBT retraction was 3.5 cm from the glenoid and 2.5 cm from the greater tuberosity. It dynamically increased from day 1 to day 90. The LHBT will retract and sit beyond the transverse humeral ligament in the bicipital groove. The LHBT retracts significantly more when early mobilization of the shoulder is allowed.

Arthroscopic isolated long head of biceps tenotomy in patients with degenerative rotator cuff tears: mid-term clinical results and prognostic factors.

INTRODUCTION: The long head of biceps tendon is frequently involved in degenerative rotator cuff tears. Therefore, this study explored the clinical results of an isolated biceps tenotomy and identified prognostic factors for improvement in pain and function. MATERIALS AND METHODS: Between 2008 and 2017, an arthroscopic isolated biceps tenotomy was performed on 64 patients with a degenerative rotator cuff tear (> 65 years). Primary outcome was patient-perceived improvement in pain and function. Potential prognostic factors for improvement in pain and function were identified. RESULTS: A perceived improvement in pain was reported in 78% of the patients at three months after surgery and in 75% at a mean follow-up of 4.2 years (1-7 years; n = 55). A perceived improvement in function was observed in 49% of patients at three months and in 76% of patients at follow-up. Patients with a preoperatively normal acromiohumeral distance (> 10 mm) reported an improvement in pain and function significantly more often. Retraction of the supraspinatus tendon Patte 3 was significantly associated with worse functional outcome. CONCLUSIONS: A biceps tenotomy can be a reliable treatment option for patients with symptomatic degenerative cuff tears who fail conservative treatment and have a normal acromiohumeral distance (> 10 mm).

Accuracy of long head of the biceps tendon palpation by physical therapists; an ultrasonographic study.

[Purpose] Examination and treatment of the long head of the biceps tendon (LHBT) requires accurate palpation. The purpose of this study was to determine physical therapists' reliability and ability to accurately palpate the LHBT in two arm positions with ultrasound as the gold standard. [Participants and Methods] Examiners palpated the LHBT within the intertubercular groove (ITG) of the humerus on the bilateral shoulders of 32 asymptomatic (21 female; 24.3 ± 1.9 years) participants in 2 arm positions. The magnitude of distance between a marker and the border of the ITG was compared between 2 positions using an independent t-test. Percent accuracy was calculated. [Results] Inter-rater reliability was poor (position 1, k=1.04; position 2, k=0.016). Overall accuracy rate was 45.7% (117/256). Accuracy was 49.2% (63/128) and 42.2% (54/128) for testing position 1 and position 2 respectively. Mean distance palpated from the groove was M=2.58 mm (± 6.2 mm) for position 1 and M=3.77 mm (± 6.6 mm) for position 2. Inaccurate palpation occurred medially 72.3% (47/65) and 93.2% (69/74) in position 1 and position 2 respectively. [Conclusion] Results of this study did not support one arm position being more accurate over another for LHBT palpation.

Accuracy of MRI in diagnosing intra-articular pathology of the long head of the biceps tendon: results with a large cohort of patients.

BACKGROUND: It is difficult to diagnose the pathology of the long head of the biceps tendon (LHBT) clinically. This study aimed to determine the diagnostic value of standard non-enhancing magnetic resonance imaging (MRI) for detecting LHBT pathology and identify the most useful diagnostic signs on MRI. METHODS: A total of 554 patients with preoperative 3-Tesla (3 T) MRI who underwent arthroscopic surgery for rotator cuff tears were retrospectively enrolled. Abnormal signs of LHBT on MRI included diameter change, contour irregularity, and alteration of signal intensity. Arthroscopic findings were classified according to tear progress and used as a reference standard: Type I, normal tendon; Type II, hourglass-shaped hypertrophic tendon with fraying extending into the bicipital groove; Type III, partial tear involving less than 50% of tendon width at the intraarticular region without fraying in the bicipital groove; Type IV, partial tear involving more than 50% of tendon width and extending into the bicipital groove; and Type V, complete tear (cutoff) of the tendon. Using receiver operating characteristic, prediction accuracies of MRI findings were assessed compared to those of arthroscopic findings. RESULTS: Arthroscopic findings showed LHBT pathology in 124 (22.4%) cases. High diagnostic efficacy was achieved when 'at least 2 abnormal signs' was set as diagnostic criteria (sensitivity: 77.9%; specificity: 93.7%; positive predictive value: 76.3%). Types II and III lesions showed the highest sensitivities (36.8 and 66.7%, respectively) in abnormal alteration of signal intensity in the parasagittal view while Type IV showed the highest sensitivity (82.3%) in diameter change in axial view. Interobserver agreements were substantial to almost perfect, with kappa value of 0.69-0.81. CONCLUSIONS: The standard non-enhancing 3 T MRI had a high diagnostic value in preoperative detection of LHBT pathology. Its accuracy was increased when diagnostic criterion was set as '2 or more abnormal signs (diameter change, contour irregularity, and alteration of signal intensity)'. The single diagnostic sign with the highest sensitivity was alteration of signal intensity in the parasagittal view.

Diagnostic accuracy of MRI for detection of tears and instability of proximal long head of biceps tendon: an evaluation of 100 shoulders compared with arthroscopy.

OBJECTIVE: To evaluate the diagnostic accuracy of magnetic resonance imaging (MRI) for detection of instability and tears of the proximal long head of biceps tendon (LHBT). To assess intraobserver and interobserver agreement. MATERIALS AND METHODS: We performed a retrospective analysis of prospectively collected data of 100 consecutive shoulders who underwent non-contrast 1.5-T MRI prior to arthroscopic surgery due to rotator cuff injury. Images were independently analyzed by two musculoskeletal radiologists. LHBT was evaluated for presence of tearing (intact, longitudinal split, partial-thickness, or full-thickness) and position (normal, subluxated, and dislocated). Anterosuperior rotator cuff tears were also assessed. The reference standard was arthroscopic surgery. The ramp test was performed in order to evaluate LHBT stability. Diagnostic performance measures were determined and Kappa coefficients assessed agreement. RESULTS: Concerning the detection of overall tears, sensitivity ranged from 71 to 73% and specificity was 73%. The specificity for full-thickness tears ranged from 75 to 96%. Overall displacement showed sensitivity ranging from 51 to 58% and specificity ranging from 70 to 86%. The specificity of overall displacement combined with anterosuperior rotator cuff tears ranged from 73 to 91%. Interobserver Kappa values were between 0.59 and 0.69. Intraobserver Kappa values were between 0.74 and 0.82. CONCLUSIONS: MRI has moderate accuracy and good agreement for detection of LHBT tears and instability. There is a tendency for increased specificity for full-thickness tears and for instability in the coexistence of anterosuperior rotator cuff tears.

Case report: Broad insertion of a large subscapularis tendon in association with congenital absence of the long head of the biceps tendon.

Congenital absence of the long head of the biceps (LHB) tendon is a rare variation in shoulder anatomy. The authors present a case of congenital absence of the long head of the biceps tendon associated with a large insertion of the subscapularis muscle. The patient initially presented with shoulder pain on overhead activity. Shoulder examination was negative for signs of a torn biceps tendon. MRI revealed congenital absence of the LHB tendon, a rim rent tear of the supraspinatus, and a large insertion of the subscapularis muscle. This is the first reported case describing a large insertion of the subscapularis muscle associated with absence of the LHB tendon.5.

Diagnostic accuracy of clinical tests directed to the long head of biceps tendon in a surgical population: a combination of old and new tests.

BACKGROUND: Our objective was to examine the clinical utility of old and new clinical tests directed to the long head of the biceps tendon (LHBT) and to quantify the importance of proper test interpretation. METHODS: A consecutive 65 patients scheduled to undergo arthroscopic surgery were selected. Before surgery, 5 clinical tests were performed: Speed, Yergason, upper cut, biceps resisted flexion (BRF), and modified BRF (mBRF) using a dumbbell. Pain in an area other than the bicipital groove was noted. The presence of LHBT disease was assessed at arthroscopy, and the clinical utility of the tests was calculated. RESULTS: The upper cut test was the most sensitive test and the one with the lowest negative likelihood ratio (0.90 and 0.26, respectively); the Yergason test was the most specific and the one with the highest positive likelihood ratio (0.83 and 2.20, respectively). BRF strength did not correlate with an LHBT lesion. The mBRF test has a sensitivity of 0.34 and a specificity of 0.75. Higher age predicted an increased risk of an LHBT lesion (1.2 times). Different interpretations of the tests can result in a difference of up to 29 percentage points in performance (ie, sensitivity). CONCLUSION: Our results suggest that the upper cut test should be used as a screening test and that after a positive result, the Speed and the Yergason tests should be used as confirmatory tests.

Complications of biceps tenodesis based on location, fixation, and indication: a review of 1526 shoulders.

BACKGROUND: Long head of the biceps tendon (LHBT) tenodesis is predominantly performed for 2 reasons: anterior shoulder pain (ASP) or structural reasons (partial tear, dislocation). METHODS: Between 2006 and 2014, all cases of primary LHBT tenodesis performed at an integrated health care system were retrospectively reviewed. Complications were analyzed by tenodesis location (below or out of the groove [OOG] vs leaving tendon in the groove [ITG]), fixation method (soft tissue vs implant), and indication (preoperative ASP vs structural). RESULTS: Among 1526 shoulders, persistent ASP did not differ by fixation method (11.0% for implant vs 12.8% for soft tissue, P = .550) or location (10.8% for OOG vs 12.9% for ITG, P = .472). Soft-tissue tenodesis cases had more frequent new-onset ASP (11.9% vs 2.6%, P < .001) and subjective weakness (8.50% vs 3.92%, P < .001) but less frequent revisions (0% vs 1.19%, P = .03) than implant tenodesis cases. No difference was found between ITG and OOG for persistent ASP (12.9% vs 10.8%, P = .550), new-onset ASP (6.5% vs 2.8%, P = .339), cramping (1.70% vs 2.31%, P = .737), deformity (4.72% vs 4.62%, P = .532), or subjective weakness (6.23% vs 4.32%, P = .334), but ITG cases had more revisions (1.51% vs 0.60%, P = .001). Among implant tenodesis cases, 1 shoulder (0.085%) sustained a fracture. CONCLUSION: The overall complication rate of LHBT tenodesis was low. Of the shoulders, 10.8% to 12.9% continued to have ASP, regardless of whether the LHBT was left ITG. Soft-tissue tenodesis cases had higher rates of new-onset ASP and subjective weakness. No significant difference for tenodesis ITG or OOG was found in biceps-related complications.

Rotator cuff tear with concomitant long head of biceps tendon (LHBT) degeneration: what is the preferred choice? Open subpectoral versus arthroscopic intraarticular tenodesis.

BACKGROUND: Lesions associated with the biceps tendon are commonly detected during arthroscopic repair of rotator cuff tears. Acquiring a preferable technique to repair both cuff and long head of biceps tendon (LHBT) lesions was the aim of several recent studies. This study aimed to compare clinical and functional outcomes of open subpectoral versus arthroscopic intraarticular tenodesis in patients with repairable rotator cuff tear associated with LHBT degeneration. PATIENTS AND METHODS: In this randomized clinical trial, 60 eligible candidates for arthroscopic rotator cuff repair (mean age 55.7 ± 6.9 years) were allocated to a control group (open subpectoral, SP) or intervention group (intraarticular, IA). In the IA group, an anchor suture was used for both rotator cuff repair and LHBT tenodesis. In the SP group, after arthroscopic repair of the rotator cuff, subpectoral tenodesis of LHBT was performed using an interference screw. Patients were evaluated for 2 years follow-up regarding pain intensity using the visual analogue scale (VAS) and shoulder function using the Constant Score and Simple Shoulder Test. RESULTS: The two groups were similar with regard to demographic characteristics and preoperative evaluations (all P > 0.05). The functional status of both groups was improved, but not significantly differently so between the two groups (P = 0.1 and P = 0.4, respectively). Pain intensity decreased during the 2-year follow-up period, similarly so in the two groups. Patient satisfaction was also similar in the two groups. CONCLUSION: Large and massive rotator cuff tears (tears > 3 cm) associated with LHBT pathologies benefited from intraarticular or subpectoral tenodesis similarly, with no differences in short- or mid-term results between these two techniques. LEVEL OF EVIDENCE: II.

Effect of patient age on accuracy of primary MRI signs of long head of biceps tearing and instability in the shoulder: an MRI-arthroscopy correlation study.

OBJECTIVE: To determine the effect of patient age on the accuracy of primary MRI signs of long head of biceps (LHB) tendon tearing and instability in the shoulder using arthroscopy as a reference standard. MATERIALS AND METHODS: Subjects with MRI studies and subsequent arthroscopy documenting LHB tendon pathology were identified and organized into three age groups (18-40, 41-60, 61-87). Normal and tendinopathic tendons were labeled grade 0, partial tears grade 1 and full tears grade 2. Two radiologists blinded to arthroscopic data graded MRI studies independently. Prevalence of disease, MRI accuracy for outcomes of interest, and inter-reader agreement were calculated. RESULTS: Eighty-nine subjects fulfilled inclusion criteria with 36 grade 0, 36 grade 1 and 17 grade 2 tendons found at arthroscopy. MRI sensitivity, regardless of age, ranged between 67-86% for grade 0, 72-94% for grade 1 and 82-94% for grade 2 tendons. Specificity ranged between 83-96% for grade 0, 75-85% for grade 1 and 99-100% for grade 2 tendons. MRI accuracy for detection of each LHB category was calculated for each age group. MRI was found to be least sensitive for grade 0 and 1 LHB tendons in the middle-aged group with sensitivity between 55-85% for grade 0 and 53-88% for grade 1 tendons. Agreement between MRI readers was moderate with an unweighted kappa statistic of 62%. CONCLUSION: MRI accuracy was moderate to excellent and agreement between MRI readers was moderate. MRI appears to be less accurate in characterizing lower grades of LHB tendon disease in middle-aged subjects.

Increased fatigue of the biceps after tenotomy of the long head of biceps tendon.

PURPOSE: The aim of this study is to evaluate the biomechanical parameters of biceps fatigue (time to claudication during elbow flexion) and strength between the shoulder where the tenotomy has been performed and the healthy arm. The hypothesis of this study was that measuring biceps fatigue may be more useful for determining functionality after tenotomy. METHODS: 52 patients from 2 hospitals were selected to undergo biomechanical tests of healthy and pathological arms, before and 12 months after surgery. The test consisted of (1) isometric measurement of maximal voluntary contraction (MVC) in elbow flexion and forearm supination (MVS) at baseline conditions. (2) Biceps fatigue test was performed by a submaximal contraction to 33% of MVC maintained at a time as well recorded to the time to claudication. (3) After claudication, measurements of the MVC and MVS were recorded. In addition, the Constant score, SSI functional scale, VAS scale and perceived symptoms were evaluated. RESULTS: Of the 52 patients included in the study, 26 met the selection criteria. Two patients were lost to follow-up. The mean age was 55 ± 5.6 years. Popeye sign was observed in 58.3% of the cases. Two patients were not satisfied with the results. Preoperatively, MVC was 193.6 ± 55.2 N, which significantly improved after tenotomy to 252.1 ± 61.2 N, but this value was less than the healthy arms (280 ± 68 N). The fatigue time decreased from 141.9 ± 69.7 s preoperatively to 94.2 ± 29.9 s after tenotomy. There was also an improvement in the strength of the arm after the fatigue test. No differences in supination force were found. The Constant, SSI and VAS rating scales improved significantly. CONCLUSIONS: Despite functional improvements of the long head of biceps tendon (LHBT) after tenotomy, this study demonstrates that the shoulder where the tenotomy has been performed will fatigue more quickly than it did preoperatively. Despite this, an improvement in the isometric contraction in flexion of the elbow with respect to the preoperative values. However, this improvement did not reach the flexion power of the contralateral healthy arm. No changes were observed in the supination force of the forearm. LEVEL OF EVIDENCE: III.