Original Article With Video Illustration
Arthroscopic Proximal Biceps Tenodesis at the Articular Margin: Evaluation of Outcomes, Complications, and Revision Rate Paul C. Brady, M.D., Pablo Narbona, M.D., Christopher R. Adams, M.D., David Huberty, M.D., Peter Parten, M.D., Robert U. Hartzler, M.D., M.S., Paolo Arrigoni, M.D., and Stephen S. Burkhart, M.D.
Purpose: The purpose of this study was to evaluate the incidence of residual pain, outcomes, and the revision rate of arthroscopic proximal biceps tenodesis high in the groove at the articular margin of the humeral head by interference screw fixation. Methods: Seven surgeons pooled data on patients who underwent an arthroscopic biceps tenodesis at the articular margin by interference screw fixation. All patients had a minimum of 50 weeks’ follow-up. Preoperative and postoperative patient data including visual analog scale scores (obtained by all surgeons), objective shoulder scores (Simple Shoulder Test and University of California, Los Angeles scores obtained by 2 and 4 surgeons, respectively), and need for revision surgery (obtained by all surgeons) were retrospectively analyzed, the results are reported, and statistical analysis was performed. Results: After the application of our exclusion criteria, 1,083 patients were included in the analysis. The mean follow-up period was 136 weeks. The overall revision surgery rate for this group was 4.1% (44 of 1,083). Revision for biceps tenodesiserelated issues was needed in only 4 cases (for a biceps tenodesiserelated revision rate of 0.4%). Pain scores improved from 6.47 preoperatively to 1.08 postoperatively (P < .0001). University of California, Los Angeles scores improved from 14.9 preoperatively to 30.1 postoperatively (P < .0001), and Simple Shoulder Test scores improved from 2.7 preoperatively to 10.2 postoperatively (P < .0001). Conclusions: Arthroscopic biceps tenodesis performed at the articular margin results in a low surgical revision rate, a low rate of residual pain, and significant improvement in objective shoulder outcome scores. Level of Evidence: Level IV, therapeutic case series.
T
he long head of the biceps (LHB) tendon is an area of much interest and controversy in the shoulder. It is believed to be a common contributor to shoulder pain and is frequently involved with other shoulder pathologies. Biceps pathologies that can contribute to pain include biceps tendinopathy, partial biceps tears, biceps tendon subluxation/sling abnormalities, and type II SLAP tears, just to name a few. Treatment of biceps-associated lesions has typically consisted of tendon debridement, tenotomy, or tenodesis. Various tenodesis techniques have arisen over the years, From The Burkhart’s Research Association of Shoulder Specialists (BRASS) Group, San Antonio, Texas, U.S.A. The authors report the following potential conflict of interest or source of funding: All authors received support from Arthrex. Received March 27, 2014; accepted August 26, 2014. Address correspondence to Paul C. Brady, M.D., Tennessee Orthopaedic Clinics, 9430 Parkwest Blvd, Ste 130, Knoxville, TN 37923, U.S.A. E-mail: [email protected] Ó 2015 by the Arthroscopy Association of North America 0749-8063/14256/$36.00 http://dx.doi.org/10.1016/j.arthro.2014.08.024
470
and the clinical results of many of these techniques have been critically evaluated with comparative studies.1-8 Recently, it has been debated what the best location for tenodesis of the biceps is and whether proximal tenodesis techniques (or those that do not address the biceps sheath) are prone to higher failure and revision rates, as well as persistent pain symptoms.9,10 The purpose of this study was to evaluate the incidence of residual pain, outcomes, and the revision rate of arthroscopic proximal biceps tenodesis high in the groove at the articular margin of the humeral head by interference screw fixation. Our hypothesis was that an arthroscopic proximal biceps tenodesis would have a low complication and revision rate, good clinical outcomes, and a low rate of residual pain.
Methods Seven orthopaedic surgeons (P.C.B., P.N., C.R.A., D.H., P.P., R.U.H., P.A.; who trained in the same shoulder fellowship), after completion of the fellowship, maintained the identical technique and similar clinical indications for arthroscopic proximal biceps tenodesis used
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 31, No 3 (March), 2015: pp 470-476
PROXIMAL BICEPS TENODESIS AT ARTICULAR MARGIN
by the senior author/fellowship director (S.S.B.). There were 7 study physicians representing 5 different states and 3 different countries. Each author performed a query of his billing and operative records searching for billing charges and surgical procedures related to arthroscopic biceps tenodesis for cases between January 2003 and December 2011. The medical records of patients incurring such charges were retrospectively reviewed, and the preoperative, operative, and follow-up records were evaluated. The inclusion criteria for the study included any patient undergoing arthroscopic shoulder surgery including an arthroscopic biceps tenodesis performed at the articular margin of the humeral head between January 1, 2003, and December 31, 2011. For surgeons to include patients in the study, they also had to have data including preoperative and postoperative visual analog scale (VAS) pain scores and the need for revision surgery recorded in the medical records. The exclusion criteria included patient follow-up period of less than 12 months and incomplete data regarding shoulder pain and the need for revision surgery. Appropriate objective and subjective shoulder measurements were collected prospectively and documented in the medical records. Recorded shoulder outcome measures included the VAS pain score; modified University of California, Los Angeles (UCLA) score; and Simple Shoulder Test (SST) score. Also recorded was whether the patient required a return trip to the operating room for treatment of the same shoulder and, if so, the reason for the return to surgery. Although all 7 authors recorded VAS and return-to-surgery data during the study period, because of individual practice variations, not all authors routinely recorded UCLA and SST data for each patient. Four authors collected UCLA data, and 2 of these 4 authors also collected SST scores. In cases in which these objective shoulder scores were not recorded, we did not use those patient data for analysis of those shoulder score parameters. The biceps tenodesis technique was a proximal interference screw tenodesis as has been described in the literature11 (Video 1, available at www.arthroscopyjournal. org). All of the authors performed follow-up of their patients until resolution of their shoulder problems and recorded reoperation information and VAS pain score data for their patients at every follow-up visit. Patient data including age, affected shoulder, postoperative diagnosis necessitating biceps tenodesis, other shoulder procedures performed at the time of biceps tenodesis, and presence or absence of a postoperative complication of nerve injury or humeral fracture were also recorded. After the data from the multiple authors were assimilated and all patient identification markers, as well as operative surgeon information, were removed, each patient was given a unique patient identification number. Preoperative and final postoperative VAS pain scores, modified UCLA scores, SST scores, and return-to-surgery
471
(for the same shoulder) data were recorded, and the mean values within each category were calculated. As noted earlier, if a surgeon participating in the study did not record modified UCLA or SST data, then patient data from those surgeons were not used in the mean calculation of those shoulder measures. A signed rank test was used to determine whether a significant difference existed between preoperative and postoperative shoulder scores for each outcome measure. The data were also analyzed (and the Wilcoxon rank sum test was used) to determine whether there were differences between the number of associated procedures performed (in addition to the biceps tenodesis) and the need for revision surgery. In addition, the Spearman correlation coefficient was used to analyze whether there was any correlation between the number of associated procedures performed and the shoulder outcome measures (VAS, SST, and UCLA scores). Statistical significance was achieved with P .05. The results were then sub-stratified by biceps tendonerelated diagnosis to determine whether significant differences existed when biceps tenodesis was performed for different shoulder conditions. Differences in outcome scores (UCLA and SST), as well as pain scores (VAS) and the need for revision surgery, were all analyzed for each biceps tendon diagnosis to determine whether significant differences existed between outcome scores or revision rates based on different biceps pathology.
Results Seven surgeons contributed data to this study. A total of 1,477 patients met the inclusion criteria. Of this patient group, 394 patients did not meet the required minimum follow-up period of 1 year, leaving 1,083 patients for data analysis. No patients were excluded because of lack of VAS or revision surgery data. All 1,083 patients (100%) had preoperative data including VAS pain scores and postoperative data including VAS scores and the need for revision surgery. Four surgeons also routinely collected UCLA scores, and these 928 patients’ scores were used in the analysis of UCLA data. Two surgeons collected SST scores (in addition to UCLA scores), and these 642 patients’ scores were used in the analysis of SST data. Patient demographic data were reviewed. For the overall group of 1,083 patients, the mean patient age was 57.8 years (range, 17 to 87 years). Eight hundred patients (73.9%) were younger than 65 years, and 283 patients (26.1%) were aged 65 years or older. The mean postoperative follow-up period was 136 weeks (range, 50 to 517 weeks). The right shoulder was affected in 673 patients (62%), whereas the left was affected in 410 patients (38%). Shoulder pathologies precipitating the decision to perform arthroscopic biceps tenodesis included biceps
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tendinopathy or partial tearing of the biceps (n ¼ 466, 43.0%), biceps tendon subluxation or instability (n ¼ 478, 44.1%), and type II SLAP tears (n ¼ 173, 16.0%). Occasionally, more than 1 biceps tendon pathology diagnosis was encountered, and this is why the pathology percentages add up to more than 100%. Associated procedures performed during arthroscopic surgery are detailed in Table 1. The more commonly performed associated procedures in addition to arthroscopic biceps tenodesis included arthroscopic rotator cuff repair in 915 cases (84.5%), subacromial decompression in 640 (59.1%), acromioplasty in 523 (48.3%), labral repair in 59 (5.4%), coracoplasty in 265 (24.5%), capsular release or lysis of adhesions in 138 (12.8%), and arthroscopic distal clavicle excision in 304 (28.2%). Overall, in the 1,083 cases, 3.2 arthroscopic procedures (including the arthroscopic biceps tenodesis procedure) were performed during surgery. Reoperation data were collected by all 7 surgeons for all 1,083 cases. There were 44 cases in which patients required a return to the operating room (for the same shoulder), for an overall reoperation rate of 4.1% (95% confidence interval, 3.0% to 5.4%). Of the 44 cases of reoperation, 20 were performed because of adhesive capsulitis, 13 had recurrent rotator cuff tears, 6 had persistent shoulder pain (only 1 of which was noted to be biceps-specific pain), and 3 had postoperative biceps tendon symptomatic ruptures (Table 2). Thus 4 of the 1,083 cases required revision for persistent biceps problems (persistent biceps pain in 1 and symptomatic ruptures in 3), for a revision rate of 0.4% (95% confidence interval, 0.1% to 0.9%) related to the biceps tenodesis procedure. Five cases underwent repeat surgery for other reasons, including suprascapular Table 1. Surgical Procedures Surgical Procedure Arthroscopic biceps tenodesis Rotator cuff repair Subacromial decompression Acromioplasty Arthroscopic distal clavicle excision Coracoplasty Capsular release/lysis of adhesions Massive rotator cuff repair Labral repair* Labral debridement MUA Other
No. 1,083 915 640 523 304 265 138 63 59 51 22 y
% (of 1,083) 100 84.5 59.1 48.3 28.1 24.5 12.7 5.8 5.4 4.7 2.0
MUA, manipulation under anesthesia. *Repairs of Bankart lesions or SLAP tears, as well as all other labral repairs. y Other procedures included decompression of paralabral or spinoganglion cyst (12), co-planing of the distal clavicle (22), PASTA (partial articular supraspinatus tendon avulsion) repair (18), shaving chondroplasty of the humerus or glenoid (16), microfracture of the humerus (4), anterosuperolateral joint reconstruction (3), partial or complete synovectomy (9), removal of loose bodies (10), os acromiale excision (2), and rotator cuff debridement (9).
Table 2. Diagnoses for Revision Surgery Diagnosis for Revision Surgery No.* % of 44 % of 1,083 Adhesive capsulitis/stiffness 20 45 1.8 Rotator cuff tear 13 30 1.2 Arthritis 5 11 0.4 Persistent pain of undetermined origin 5 11 0.4 not around biceps 3 7 0.3 Symptomatic biceps rupturey Persistent pain of undetermined origin 1 2 0.1 in area of bicepsy 6 14 0.6 Otherz *The numbers add up to greater than 44 and the percentages add up to greater than 100% because some patients had more than 1 diagnosis for revision surgery. y These categories are those believed to be related to the patient’s previous biceps tenodesis procedure. z Other diagnoses included trauma (2), GraftRope (Arthrex, Naples, FL) failure (2), rotator cuff ossification (2).
neuropathy (1), anterosuperolateral jointerelated problems (2), and development of heterotopic ossification (2). Some revision cases had more than 1 postoperative diagnosis listed. All surgeons collected VAS scores preoperatively and postoperatively. For the 1,083 patients, the VAS pain score averaged 6.47 preoperatively and the final postoperative VAS score averaged 1.08. This was statistically significant (P < .0001). Four of the 7 surgeons routinely collected UCLA scores. The mean UCLA score for this group of 928 patients was 14.88 preoperatively and improved to 30.09 postoperatively. This was also a statistically significant improvement (P ¼ .0001). Two surgeons routinely collected SST data. The preoperative SST averaged 2.72 for these 642 patients and improved to 10.21 postoperatively. Again, this reached statistical significance (P ¼ .0001). Correlation analysis showed no statistical correlation between the number of associated procedures performed and the postoperative change from preoperative VAS score and UCLA score (Spearman correlation coefficient ¼ 0.02529 and 0.01933, respectively). However, the number of procedures was moderately correlated with the change in the SST score (Spearman correlation coefficient ¼ 0.41415, P < .0001). The revision rate was not different based on the number of associated procedures performed (P ¼ .3102, Wilcoxon rank sum test). Comparison of preoperative and postoperative shoulder scores (including VAS, SST, and UCLA) did not vary substantially by age group (Table 3). The rate of the need for revision surgery for varying biceps tendon diagnoses ranged from 2.7% to 6.5%. No patient had a postoperative nerve injury or humeral fracture at the time of last follow-up.
Discussion This study sheds important light on the subject of arthroscopic biceps tenodesis performed high in the
PROXIMAL BICEPS TENODESIS AT ARTICULAR MARGIN Table 3. Comparison of Shoulder Scores Based on Age Group
VAS score improvement SST score improvement UCLA score improvement
Age
Arthroscopic Proximal Biceps Tenodesis at the Articular Margin: Evaluation of Outcomes, Complications, and Revision Rate Paul C. Brady, M.D., Pablo Narbona, M.D., Christopher R. Adams, M.D., David Huberty, M.D., Peter Parten, M.D., Robert U. Hartzler, M.D., M.S., Paolo Arrigoni, M.D., and Stephen S. Burkhart, M.D.
Purpose: The purpose of this study was to evaluate the incidence of residual pain, outcomes, and the revision rate of arthroscopic proximal biceps tenodesis high in the groove at the articular margin of the humeral head by interference screw fixation. Methods: Seven surgeons pooled data on patients who underwent an arthroscopic biceps tenodesis at the articular margin by interference screw fixation. All patients had a minimum of 50 weeks’ follow-up. Preoperative and postoperative patient data including visual analog scale scores (obtained by all surgeons), objective shoulder scores (Simple Shoulder Test and University of California, Los Angeles scores obtained by 2 and 4 surgeons, respectively), and need for revision surgery (obtained by all surgeons) were retrospectively analyzed, the results are reported, and statistical analysis was performed. Results: After the application of our exclusion criteria, 1,083 patients were included in the analysis. The mean follow-up period was 136 weeks. The overall revision surgery rate for this group was 4.1% (44 of 1,083). Revision for biceps tenodesiserelated issues was needed in only 4 cases (for a biceps tenodesiserelated revision rate of 0.4%). Pain scores improved from 6.47 preoperatively to 1.08 postoperatively (P < .0001). University of California, Los Angeles scores improved from 14.9 preoperatively to 30.1 postoperatively (P < .0001), and Simple Shoulder Test scores improved from 2.7 preoperatively to 10.2 postoperatively (P < .0001). Conclusions: Arthroscopic biceps tenodesis performed at the articular margin results in a low surgical revision rate, a low rate of residual pain, and significant improvement in objective shoulder outcome scores. Level of Evidence: Level IV, therapeutic case series.
T
he long head of the biceps (LHB) tendon is an area of much interest and controversy in the shoulder. It is believed to be a common contributor to shoulder pain and is frequently involved with other shoulder pathologies. Biceps pathologies that can contribute to pain include biceps tendinopathy, partial biceps tears, biceps tendon subluxation/sling abnormalities, and type II SLAP tears, just to name a few. Treatment of biceps-associated lesions has typically consisted of tendon debridement, tenotomy, or tenodesis. Various tenodesis techniques have arisen over the years, From The Burkhart’s Research Association of Shoulder Specialists (BRASS) Group, San Antonio, Texas, U.S.A. The authors report the following potential conflict of interest or source of funding: All authors received support from Arthrex. Received March 27, 2014; accepted August 26, 2014. Address correspondence to Paul C. Brady, M.D., Tennessee Orthopaedic Clinics, 9430 Parkwest Blvd, Ste 130, Knoxville, TN 37923, U.S.A. E-mail: [email protected] Ó 2015 by the Arthroscopy Association of North America 0749-8063/14256/$36.00 http://dx.doi.org/10.1016/j.arthro.2014.08.024
470
and the clinical results of many of these techniques have been critically evaluated with comparative studies.1-8 Recently, it has been debated what the best location for tenodesis of the biceps is and whether proximal tenodesis techniques (or those that do not address the biceps sheath) are prone to higher failure and revision rates, as well as persistent pain symptoms.9,10 The purpose of this study was to evaluate the incidence of residual pain, outcomes, and the revision rate of arthroscopic proximal biceps tenodesis high in the groove at the articular margin of the humeral head by interference screw fixation. Our hypothesis was that an arthroscopic proximal biceps tenodesis would have a low complication and revision rate, good clinical outcomes, and a low rate of residual pain.
Methods Seven orthopaedic surgeons (P.C.B., P.N., C.R.A., D.H., P.P., R.U.H., P.A.; who trained in the same shoulder fellowship), after completion of the fellowship, maintained the identical technique and similar clinical indications for arthroscopic proximal biceps tenodesis used
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 31, No 3 (March), 2015: pp 470-476
PROXIMAL BICEPS TENODESIS AT ARTICULAR MARGIN
by the senior author/fellowship director (S.S.B.). There were 7 study physicians representing 5 different states and 3 different countries. Each author performed a query of his billing and operative records searching for billing charges and surgical procedures related to arthroscopic biceps tenodesis for cases between January 2003 and December 2011. The medical records of patients incurring such charges were retrospectively reviewed, and the preoperative, operative, and follow-up records were evaluated. The inclusion criteria for the study included any patient undergoing arthroscopic shoulder surgery including an arthroscopic biceps tenodesis performed at the articular margin of the humeral head between January 1, 2003, and December 31, 2011. For surgeons to include patients in the study, they also had to have data including preoperative and postoperative visual analog scale (VAS) pain scores and the need for revision surgery recorded in the medical records. The exclusion criteria included patient follow-up period of less than 12 months and incomplete data regarding shoulder pain and the need for revision surgery. Appropriate objective and subjective shoulder measurements were collected prospectively and documented in the medical records. Recorded shoulder outcome measures included the VAS pain score; modified University of California, Los Angeles (UCLA) score; and Simple Shoulder Test (SST) score. Also recorded was whether the patient required a return trip to the operating room for treatment of the same shoulder and, if so, the reason for the return to surgery. Although all 7 authors recorded VAS and return-to-surgery data during the study period, because of individual practice variations, not all authors routinely recorded UCLA and SST data for each patient. Four authors collected UCLA data, and 2 of these 4 authors also collected SST scores. In cases in which these objective shoulder scores were not recorded, we did not use those patient data for analysis of those shoulder score parameters. The biceps tenodesis technique was a proximal interference screw tenodesis as has been described in the literature11 (Video 1, available at www.arthroscopyjournal. org). All of the authors performed follow-up of their patients until resolution of their shoulder problems and recorded reoperation information and VAS pain score data for their patients at every follow-up visit. Patient data including age, affected shoulder, postoperative diagnosis necessitating biceps tenodesis, other shoulder procedures performed at the time of biceps tenodesis, and presence or absence of a postoperative complication of nerve injury or humeral fracture were also recorded. After the data from the multiple authors were assimilated and all patient identification markers, as well as operative surgeon information, were removed, each patient was given a unique patient identification number. Preoperative and final postoperative VAS pain scores, modified UCLA scores, SST scores, and return-to-surgery
471
(for the same shoulder) data were recorded, and the mean values within each category were calculated. As noted earlier, if a surgeon participating in the study did not record modified UCLA or SST data, then patient data from those surgeons were not used in the mean calculation of those shoulder measures. A signed rank test was used to determine whether a significant difference existed between preoperative and postoperative shoulder scores for each outcome measure. The data were also analyzed (and the Wilcoxon rank sum test was used) to determine whether there were differences between the number of associated procedures performed (in addition to the biceps tenodesis) and the need for revision surgery. In addition, the Spearman correlation coefficient was used to analyze whether there was any correlation between the number of associated procedures performed and the shoulder outcome measures (VAS, SST, and UCLA scores). Statistical significance was achieved with P .05. The results were then sub-stratified by biceps tendonerelated diagnosis to determine whether significant differences existed when biceps tenodesis was performed for different shoulder conditions. Differences in outcome scores (UCLA and SST), as well as pain scores (VAS) and the need for revision surgery, were all analyzed for each biceps tendon diagnosis to determine whether significant differences existed between outcome scores or revision rates based on different biceps pathology.
Results Seven surgeons contributed data to this study. A total of 1,477 patients met the inclusion criteria. Of this patient group, 394 patients did not meet the required minimum follow-up period of 1 year, leaving 1,083 patients for data analysis. No patients were excluded because of lack of VAS or revision surgery data. All 1,083 patients (100%) had preoperative data including VAS pain scores and postoperative data including VAS scores and the need for revision surgery. Four surgeons also routinely collected UCLA scores, and these 928 patients’ scores were used in the analysis of UCLA data. Two surgeons collected SST scores (in addition to UCLA scores), and these 642 patients’ scores were used in the analysis of SST data. Patient demographic data were reviewed. For the overall group of 1,083 patients, the mean patient age was 57.8 years (range, 17 to 87 years). Eight hundred patients (73.9%) were younger than 65 years, and 283 patients (26.1%) were aged 65 years or older. The mean postoperative follow-up period was 136 weeks (range, 50 to 517 weeks). The right shoulder was affected in 673 patients (62%), whereas the left was affected in 410 patients (38%). Shoulder pathologies precipitating the decision to perform arthroscopic biceps tenodesis included biceps
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tendinopathy or partial tearing of the biceps (n ¼ 466, 43.0%), biceps tendon subluxation or instability (n ¼ 478, 44.1%), and type II SLAP tears (n ¼ 173, 16.0%). Occasionally, more than 1 biceps tendon pathology diagnosis was encountered, and this is why the pathology percentages add up to more than 100%. Associated procedures performed during arthroscopic surgery are detailed in Table 1. The more commonly performed associated procedures in addition to arthroscopic biceps tenodesis included arthroscopic rotator cuff repair in 915 cases (84.5%), subacromial decompression in 640 (59.1%), acromioplasty in 523 (48.3%), labral repair in 59 (5.4%), coracoplasty in 265 (24.5%), capsular release or lysis of adhesions in 138 (12.8%), and arthroscopic distal clavicle excision in 304 (28.2%). Overall, in the 1,083 cases, 3.2 arthroscopic procedures (including the arthroscopic biceps tenodesis procedure) were performed during surgery. Reoperation data were collected by all 7 surgeons for all 1,083 cases. There were 44 cases in which patients required a return to the operating room (for the same shoulder), for an overall reoperation rate of 4.1% (95% confidence interval, 3.0% to 5.4%). Of the 44 cases of reoperation, 20 were performed because of adhesive capsulitis, 13 had recurrent rotator cuff tears, 6 had persistent shoulder pain (only 1 of which was noted to be biceps-specific pain), and 3 had postoperative biceps tendon symptomatic ruptures (Table 2). Thus 4 of the 1,083 cases required revision for persistent biceps problems (persistent biceps pain in 1 and symptomatic ruptures in 3), for a revision rate of 0.4% (95% confidence interval, 0.1% to 0.9%) related to the biceps tenodesis procedure. Five cases underwent repeat surgery for other reasons, including suprascapular Table 1. Surgical Procedures Surgical Procedure Arthroscopic biceps tenodesis Rotator cuff repair Subacromial decompression Acromioplasty Arthroscopic distal clavicle excision Coracoplasty Capsular release/lysis of adhesions Massive rotator cuff repair Labral repair* Labral debridement MUA Other
No. 1,083 915 640 523 304 265 138 63 59 51 22 y
% (of 1,083) 100 84.5 59.1 48.3 28.1 24.5 12.7 5.8 5.4 4.7 2.0
MUA, manipulation under anesthesia. *Repairs of Bankart lesions or SLAP tears, as well as all other labral repairs. y Other procedures included decompression of paralabral or spinoganglion cyst (12), co-planing of the distal clavicle (22), PASTA (partial articular supraspinatus tendon avulsion) repair (18), shaving chondroplasty of the humerus or glenoid (16), microfracture of the humerus (4), anterosuperolateral joint reconstruction (3), partial or complete synovectomy (9), removal of loose bodies (10), os acromiale excision (2), and rotator cuff debridement (9).
Table 2. Diagnoses for Revision Surgery Diagnosis for Revision Surgery No.* % of 44 % of 1,083 Adhesive capsulitis/stiffness 20 45 1.8 Rotator cuff tear 13 30 1.2 Arthritis 5 11 0.4 Persistent pain of undetermined origin 5 11 0.4 not around biceps 3 7 0.3 Symptomatic biceps rupturey Persistent pain of undetermined origin 1 2 0.1 in area of bicepsy 6 14 0.6 Otherz *The numbers add up to greater than 44 and the percentages add up to greater than 100% because some patients had more than 1 diagnosis for revision surgery. y These categories are those believed to be related to the patient’s previous biceps tenodesis procedure. z Other diagnoses included trauma (2), GraftRope (Arthrex, Naples, FL) failure (2), rotator cuff ossification (2).
neuropathy (1), anterosuperolateral jointerelated problems (2), and development of heterotopic ossification (2). Some revision cases had more than 1 postoperative diagnosis listed. All surgeons collected VAS scores preoperatively and postoperatively. For the 1,083 patients, the VAS pain score averaged 6.47 preoperatively and the final postoperative VAS score averaged 1.08. This was statistically significant (P < .0001). Four of the 7 surgeons routinely collected UCLA scores. The mean UCLA score for this group of 928 patients was 14.88 preoperatively and improved to 30.09 postoperatively. This was also a statistically significant improvement (P ¼ .0001). Two surgeons routinely collected SST data. The preoperative SST averaged 2.72 for these 642 patients and improved to 10.21 postoperatively. Again, this reached statistical significance (P ¼ .0001). Correlation analysis showed no statistical correlation between the number of associated procedures performed and the postoperative change from preoperative VAS score and UCLA score (Spearman correlation coefficient ¼ 0.02529 and 0.01933, respectively). However, the number of procedures was moderately correlated with the change in the SST score (Spearman correlation coefficient ¼ 0.41415, P < .0001). The revision rate was not different based on the number of associated procedures performed (P ¼ .3102, Wilcoxon rank sum test). Comparison of preoperative and postoperative shoulder scores (including VAS, SST, and UCLA) did not vary substantially by age group (Table 3). The rate of the need for revision surgery for varying biceps tendon diagnoses ranged from 2.7% to 6.5%. No patient had a postoperative nerve injury or humeral fracture at the time of last follow-up.
Discussion This study sheds important light on the subject of arthroscopic biceps tenodesis performed high in the
PROXIMAL BICEPS TENODESIS AT ARTICULAR MARGIN Table 3. Comparison of Shoulder Scores Based on Age Group
VAS score improvement SST score improvement UCLA score improvement
Age
