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Arthroscopic Suprapectoral and Open Subpectoral Biceps Tenodesis: A Comparison of Minimum 2-Year Clinical Outcomes Brian C. Werner, Cody L. Evans, Russel E. Holzgrefe, Jeffrey M. Tuman, Joseph M. Hart, Eric W. Carson, David R. Diduch, Mark D. Miller and Stephen F. Brockmeier Am J Sports Med 2014 42: 2583 originally published online September 8, 2014 DOI: 10.1177/0363546514547226 The online version of this article can be found at: http://ajs.sagepub.com/content/42/11/2583

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In-Depth

Arthroscopic Suprapectoral and Open Subpectoral Biceps Tenodesis A Comparison of Minimum 2-Year Clinical Outcomes Brian C. Werner,* MD, Cody L. Evans,* MD, Russel E. Holzgrefe,* BS, BBA, Jeffrey M. Tuman,* MD, Joseph M. Hart,* PhD, Eric W. Carson,* MD, David R. Diduch,* MD, Mark D. Miller,* MD, and Stephen F. Brockmeier,*y MD Investigation performed at the University of Virginia Health System, Charlottesville, Virginia, USA Background: While a vast body of literature exists describing biceps tenodesis techniques and evaluating the biomechanical aspects of tenodesis locations or various implants, little literature presents useful clinical outcomes to guide surgeons in their decision to perform a particular method of tenodesis. Purpose/Hypothesis: To compare the clinical outcomes of open subpectoral biceps tenodesis (OSPBT) and arthroscopic suprapectoral biceps tenodesis (ASPBT). Our null hypothesis was that both methods would yield satisfactory results with regard to shoulder and biceps function, postoperative shoulder scores, pain relief, and complications. Study Design: Cohort study; Level of evidence, 3. Methods: Patients who underwent either ASPBT or OSPBT for isolated superior labrum or long head of the biceps lesions with a minimum follow-up of 2 years were evaluated with several validated clinical outcome measures and physical examinations including range of motion and strength. Results: Between 2007 and 2011, a total of 82 patients met all inclusion and exclusion criteria, which included 32 patients with ASPBT and 50 patients with OSPBT; 27 of 32 (84.4%) patients with ASPBT and 35 of 50 (70.0%) patients with OSPBT completed clinical follow-up. Overall outcomes for both procedures were satisfactory. No significant differences were noted in postoperative Constant-Murley (ASPBT: 90.7; OSPBT: 91.8; P = .755), American Shoulder and Elbow Surgeons (ASPBT: 90.1; OSPBT: 88.4; P = .735), Single Assessment Numeric Evaluation (ASPBT: 87.4; OSPBT: 86.8; P = .901), Simple Shoulder Test (ASPBT: 10.4; OSPBT: 10.6; P = .762), long head of the biceps (ASPBT: 91.6; OSPBT: 93.6; P = .481), or Veterans RAND 36-Item Health Survey (ASPBT: 81.0; OSPBT: 80.1; P = .789) scores. No significant range of motion or strength differences was noted between the procedures. Conclusion: Both ASPBT and OSPBT yield excellent clinical and functional results for the management of isolated superior labrum or long head of the biceps lesions. No significant differences in clinical outcomes as determined by several validated outcome measures were found between the 2 tenodesis methods, nor were any significant range of motion or strength deficits noted at a minimum 2 years postoperatively. Keywords: biceps tenodesis; open subpectoral; arthroscopic suprapectoral; SLAP tear; long head of the biceps

Lesions of the intra-articular long head of the biceps (LHB) tendon have long been considered significant pain generators in the shoulder.2,18,59 Despite considerable research into the anatomy of the LHB and the various pathological conditions that affect it, there remains persistent controversy regarding the function of the LHB and, most importantly, the appropriate management of its disorders.52 While nonoperative options exist for mild symptoms or lesser lesions such as tendinopathy or partial tears of the LHB, surgical intervention has been shown to be appropriate therapy for LHB partial tears, LHB subluxation, biceps pulley lesions, and superior labrum anterior-posterior (SLAP) lesions.z

y Address correspondence to Stephen F. Brockmeier, MD, Sports Medicine and Shoulder Surgery, Department of Orthopaedic Surgery, University of Virginia Health System, 400 Ray C. Hunt Drive, Suite 330, Charlottesville, VA 22908, USA (e-mail: [email protected]). *Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, USA. Presented at the 40th annual meeting of the AOSSM, Seattle, Washington, July 2014. One or more of the authors has declared the following potential conflict of interest or source of funding: S.F.B. has received sponsorship/ funding for the present study from Arthrex Inc.

The American Journal of Sports Medicine, Vol. 42, No. 11 DOI: 10.1177/0363546514547226 Ó 2014 The Author(s)

z

References 4, 5, 8, 9, 21, 29, 38, 44, 50, 55, 59, 60, 63, 70, 72, 82.

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The choice of an optimal surgical procedure for LHB tendon lesions remains controversial, with biceps tenotomy and tenodesis being the 2 most commonly performed procedures.22,29,52,55,69,72,80,81 Both tenotomy and tenodesis have gained widespread acceptance as quick, easy, and costeffective procedures to manage both isolated biceps tendon lesions as well as combined lesions of the rotator cuff and biceps-labrum complex.18 Biceps tenotomy can be performed relatively simply and reproducibly and provides predictable pain relief without requiring significant postoperative rehabilitation.24,35,44,52,72 In general, biceps tenotomy is indicated for patients aged over 60 years who are not involved in heavy labor or high-demand activities.22,39,72,76 Decreased postoperative rehabilitation allows for a quicker return to activities and a decreased risk of postoperative stiffness. Although tenotomy is simpler to perform, it may result in a cosmetic deformity, cramping, and fatigue pain of the biceps and a decrease in elbow flexion and supination power.5,7,10,12,19 These observed limitations of biceps tenotomy led to the development of biceps tenodesis. Initially described several decades ago,16,21,28,46 tenodesis has recently seen significantly increased utilization in the management of numerous disorders of the LHB tendon. Tenodesis is the currently preferred technique for managing LHB lesions in younger persons, athletes, laborers, and those wishing to avoid likely cosmetic deformities.52 While there is no consensus in the literature regarding tenotomy versus tenodesis, tenodesis allows better ability to return to physical activity, fewer cosmetic deformities, and closer approximation of the normal anatomy, despite longer rehabilitation times and increased technical difficulty.§ Tenodesis of the LHB can be performed open,k minimally open,43,59,73,78 or arthroscopically.{ Tenodesis can be positioned in the bicipital groove, the ‘‘suprapectoral’’ position below the bicipital groove at the superior border of the pectoralis major tendon,# the subpectoral position,** or in other positions such as to the conjoint tendon or soft tissue tenodesis sites.20,40,67,75 Suprapectoral tenodesis is easy to accomplish arthroscopically, whereas subpectoral tenodesis is performed in an open fashion through a longitudinal skin incision at the lower border of the pectoralis major.26,43,45,59 Various tenodesis fixation methods exist including suture anchors and interference screws.yy While a vast body of literature exists describing biceps tenodesis techniques and evaluating the biomechanical aspects of tenodesis locations or various implants, surprisingly little literature presents useful clinical outcomes to guide surgeons in their decision to perform a particular method of tenodesis. Despite being 2 of the most commonly utilized techniques for tenodesis, a notable paucity of

§

References 3, 5-7, 16, 29, 39, 43, 44, 46, 55, 65, 80, 81.

k

References 4, 5, 16, 21, 26, 43-45, 48, 50, 60, 62.

studies report clinical outcomes after arthroscopic suprapectoral biceps tenodesis (ASPBT)6,9,12,42,66,67 or open subpectoral biceps tenodesis (OSPBT).4,5,44,50 Furthermore, there are no existing studies that directly compare the clinical outcomes of ASPBT and OSPBT in a single cohort of patients. Patzer et al59 recently published a biomechanical cadaveric study comparing tenodesis fixation techniques in both the suprapectoral and subpectoral positions. The authors found that interference screws are the appropriate devices for suprapectoral and subpectoral biceps tenodeses for resisting cyclic loading but made no conclusions regarding the position of tenodesis. Sanders et al66 recently indirectly compared open subpectoral and arthroscopic suprapectoral methods but again made no conclusions regarding specific postoperative clinical differences between the two. The goal of this study was to provide the first data on outcomes comparing the clinical results of OSPBT and ASPBT. Our null hypothesis was that both methods would yield satisfactory results with regard to shoulder and biceps function, postoperative shoulder scores, pain relief, and complications.

MATERIALS AND METHODS After institutional review board approval was obtained, a retrospective review of all patients who underwent biceps tenodesis at our institution from 2007-2011 was completed. Inclusion criteria were (1) isolated SLAP tears or biceps lesions, including tenosynovitis, complete or partial tearing, or subluxation; (2) minimum of 2 years’ postoperative follow-up; and (3) records available for review. Exclusion criteria were (1) concomitant rotator cuff repair or concomitant procedures to address glenohumeral instability, (2) preoperative range of motion deficit due to frozen shoulder or glenohumeral arthritis, (3) contralateral shoulder injury or surgery, (4) concomitant shoulder arthroplasty, (5) subsequent procedures performed on the operative shoulder, and (6) age younger than 18 years. The medical records of all patients meeting inclusion and exclusion criteria were retrospectively reviewed. Demographic data, including age, sex, body mass index (BMI), smoking status, dominant shoulder, and workers’ compensation status, were collected. Factors specific to the patient’s shoulder complaints were also recorded, including mechanism of injury and prior nonoperative interventions. Surgical records were reviewed to determine the type of tenodesis (open subpectoral or arthroscopic suprapectoral), concomitant shoulder injuries (eg, partial rotator cuff tear, subacromial impingement, acromioclavicular arthritis), and concomitant surgical procedures (eg, rotator cuff debridement, subacromial decompression, or distal clavicle excision). Documentation from follow-up visits was also reviewed.

{

References 1, 7, 8, 11, 17, 23, 36, 38, 40, 41, 53, 65, 68, 75.

#

References 1, 7, 8, 11, 17, 23, 27, 36, 38, 41, 49, 53, 58, 59, 65, 68.

**

References 4, 5, 16, 21, 26, 44-46, 48, 51, 59, 62, 78.

yy

References 26, 27, 32, 36, 41, 43, 48, 56-58, 64, 71.

Operative Technique All tenodesis procedures were performed by 1 of 4 sports fellowship–trained orthopaedic surgeons with extensive

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Arthroscopic and Open Tenodesis Clinical Outcomes

experience in each technique. The choice of technique was by surgeon preference; thus, patients were not randomized to each technique. During the study period, 2 surgeons exclusively performed OSPBT, and 2 surgeons exclusively performed ASPBT. For each tenodesis technique, standard arthroscopic portals were established. A spinal needle was placed percutaneously through the LHB tendon between 1 and 2 cm distal to its superior labral attachment. A PDS suture (Ethicon) was passed through the tendon using a needle to facilitate retrieval (for open subpectoral) or for control of the tendon (for arthroscopic suprapectoral). The biceps was then released from its superior labral attachment. The remaining superior labrum was gently debrided as indicated. Arthroscopic Suprapectoral Biceps Tenodesis. Arthroscopic suprapectoral biceps tenodesis was performed according to techniques previously published by several authors.15,31,42 In this technique, the arthroscope was redirected into the subacromial space. Using a direct lateral portal, bursectomy was performed to facilitate visualization of the biceps tendon in the subdeltoid space. The camera was then repositioned into the lateral portal, and the biceps tendon was identified in its sheath within the intertubercular groove. Cautery was used to release the biceps from its sheath, and an appropriate site for tenodesis was localized just proximal to the pectoralis major tendon, which was easily visible using this approach. A spinal needle was used to localize an appropriate position and angle through which tenodesis fixation could be placed. A portal was established at this location and a guide wire placed. A cannulated reamer was drilled to the appropriate depth. The proximal tendon was stabilized using the previously placed PDS suture, and an appropriately sized interference screw implant was then used to affix the tendon into the reamed tenodesis site. Care was taken to avoid wrapping the tendon with the implant as the implant was tightened. Open Subpectoral Biceps Tenodesis. Open subpectoral biceps tenodesis was performed using the method described by Mazzocca et al.45 For this technique, the LHB was tenotomized arthroscopically as above. After this, a 3-cm vertical incision was made near the axillary fold. The overlying fascia and fatty tissue were incised. A pointed Hohmann retractor was placed under the pectoralis major and a Chandler retractor placed over the medial aspect of the humerus to assist in visualization. The soft tissue was dissected, and the LHB was isolated just posterior to the pectoralis major insertion. A right-angle clamp was used to pull the biceps tendon from underneath the pectoralis major and deliver it through the incision. The bicipital groove was palpated, and the periosteum was reflected using an elevator at a point just proximal to the inferior edge of the pectoralis major. The myotendinous transition of the biceps was identified, and the terminal 20 mm of tendon was whip-stitched with a No. 2 highstrength suture. The remaining biceps tendon was then amputated at this level. A guide wire was placed, and a cannulated reamer was drilled to a depth of 20 mm. An appropriately sized interference screw implant was then used to affix the tendon into the reamed tenodesis site.

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Postoperative Management The postoperative management of all included patients was the same regardless of the tenodesis technique. Patients were immobilized in a sling, performing only pendulum exercises until 2 weeks postoperatively. After sutures were removed, physical therapy including range of motion was instituted. The sling was discontinued by 6 weeks postoperatively, at which point rotator cuff, deltoid, and periscapular muscle strengthening was instituted. Patients were released to full activities between 3 and 4 months postoperatively.

Clinical Follow-up Patients were recruited for in-person study visits. Study visits included completion of 5 validated outcome measures: (1) Constant-Murley shoulder outcome score,14,37 (2) American Shoulder and Elbow Surgeons (ASES) score (self-report section and physician assessment section),47,54,74 (3) Single Assessment Numeric Evaluation (SANE) score,61,79 (4) Simple Shoulder Test (SST) score,25,74 and (5) Veterans RAND 36-Item Health Survey (VR-36) score33,34 as well as 1 applicable but nonvalidated measure: the LHB score.67 The questionnaires were provided to the patients and filled out in the same order for each participant. Clinical examinations included assessments of both operative and nonoperative shoulder ranges of motion, including abduction, forward flexion, external rotation at 0° and 90° of shoulder abduction, and internal rotation at 90° of shoulder abduction. Because of the presence of an axillary incision in the open subpectoral group, examiners were not blinded to the type of tenodesis performed. The assessment of elbow range of motion included flexion, extension, supination, and pronation of both the operative and nonoperative extremities. Bilateral elbow flexion and extension strength were assessed using a dynamometer.

Statistical Analysis A power analysis was conducted to determine the minimum patient sample size using G*Power 3 (HeinrichHeine-Universita¨t Du¨sseldorf; http://www.gpower.hhu.de/ en.html). A power analysis was performed for each of 3 key clinical endpoints of the study: Constant-Murley score, ASES score, and range of motion. Also, SDs were purposely overestimated to further reduce the risk of errors. Constant-Murley Score. Assuming an SD of 610 within each group and a significance level (a) of .05, the minimum number of patients in each group required to detect a difference of 12 points is 16 patients. ASES (Self) Score. The reported minimal clinically important difference in the ASES score ranges from 12 to 17. Assuming an SD of 612 within each group, the minimum number of patients required in each group to detect a difference of 15 points at a significance level (a) of .05 is 15 patients. Range of Motion. Assuming an SD of 613 within each individual range of motion measurement, to detect a difference of 15° at a significance level (a) of .05, the minimum

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TABLE 1 Comparison of ASPBT and OSPBT Cohortsa

Patients at follow-up, n (%) Age, mean 6 SD, y BMI, mean 6 SD, kg/m2 Male sex, n (%) Workers’ compensation, n (%) Smoker, n (%) Dominant arm, n (%) Concomitant procedures, n (%) Rotator cuff repairb Acromioplasty Distal clavicle excision

ASPBT

OSPBT

P Value

27/32 (84.4) 49.3 6 7.2 28.6 6 4.6 18 (66.7) 2 (7.4) 8 (29.6) 16 (59.3)

35/50 (70.0) 52.3 6 7.7 29.7 6 5.5 22 (62.9) 3 (8.6) 10 (28.6) 23 (65.7)

.153 .478 .756 .867 .927 .602

0 (0) 21 (77.8) 8 (29.6)

0 (0) 26 (74.3) 9 (25.7)

.750 .732

a

ASPBT, arthroscopic suprapectoral biceps tenodesis; BMI, body mass index; OSPBT, open subpectoral biceps tenodesis. Does not include rotator cuff tears, which did not undergo repair.

b

number of patients required in each group is 17. Based on the above power analysis calculations, a minimum of 17 patients in each group was required to satisfy all key outcome measures in this study. Means and SDs were calculated for continuous variables (age, BMI, outcome measures, range of motion) and compared using an independent-samples Student t test. Categorical variables (patient sex, smoking status, workers’ compensation status, dominant arm, additional procedures) were compared using x2 tests. For all statistical tests, P \ .05 was considered significant. Statistical analysis was performed using SPSS software (v 21, SPSS Inc).

RESULTS Over the study period of 2007-2011, a total of 363 biceps tenodesis procedures were performed at our institution. After application of the inclusion and exclusion criteria, 82 patients met all criteria, which included 32 patients with ASPBT and 50 patients with OSPBT. The majority of excluded patients were because of concomitant rotator cuff repair or prior shoulder procedures. Of the included patients, 27 of 32 (84.4%) patients with ASPBT and 35 of 50 (70.0%) patients with OSPBT completed clinical followup. Of the 5 patients with ASPBT who did not complete clinical follow-up, 3 were unreachable because of inaccurate contact information, and 2 moved from the area and were unable to return for examination. Of the 15 patients with OSPBT who did not complete clinical follow-up, 13 were unreachable because of inaccurate contact information, 1 patient was deceased, and the remaining patient had moved from the area and was unable to return for examination. The minimum follow-up for all patients was 2 years. The mean follow-up for all patients who returned for clinical follow-up was 3.1 years (range, 2.2-5.4 years). The mean follow-up for the ASPBT cohort was 2.9 years (range, 2.2-4.0 years). The mean follow-up for the OSPBT cohort was 3.3 years (range, 2.2-5.4 years). A retrospective chart review identified baseline characteristics of the ASPBT and OSPBT cohorts, which are

TABLE 2 Clinical Outcome Measuresa ASPBT Constant-Murley ASES (self) SANEb SST LHB score VR-36

90.7 90.1 87.4 10.4 91.6 81.0

6 6 6 6 6 6

10.4 13.6 13.9 2.1 8.3 8.1

OSPBT 91.8 88.4 86.8 10.6 93.6 80.1

6 6 6 6 6 6

6.6 10.0 10.7 1.4 5.8 8.9

P Value .755 .735 .901 .762 .481 .789

a

Values are reported as mean 6 SD. ASES, American Shoulder and Elbow Surgeons; ASPBT, arthroscopic suprapectoral biceps tenodesis; LHB, long head of the biceps; OSPBT, open subpectoral biceps tenodesis; SANE, Single Assessment Numeric Evaluation; SST, Simple Shoulder Test; VR-36, Veterans RAND 36-Item Health Survey. b The SANE score is expressed as percentages.

detailed in Table 1. No significant differences were noted between the 2 cohorts with regard to mean age, BMI, sex, workers’ compensation status, smoking, involvement of the dominant arm, or concomitant procedures. Patients were recruited to return for study visits, which included questionnaires as detailed above and a clinical examination. Questionnaire results are reported in Table 2. At a mean of 3.1 years postoperatively, no significant differences between ASPBT and OSPBT were noted in the Constant-Murley score (ASPBT: 90.7; OSPBT: 91.8; P = .755), ASES score (ASPBT: 90.1; OSPBT: 88.4; P = .735), SANE score (ASPBT: 87.4%; OSPBT: 86.8%; P = .901), SST score (ASPBT: 10.4; OSPBT: 10.6; P = .762), LHB score (ASPBT: 91.6; OSPBT: 93.6; P = .481), or healthrelated quality of life as reported in the VR-36 (ASPBT: 81.0; OSPBT: 80.1; P = .789). Range of motion was assessed for both the operative and nonoperative shoulders. Range of motion results for the operative extremity were normalized to that of the nonoperative shoulder (measured at the same clinical visit by the same examiner) and reported as the percentage of the normal shoulder (operative shoulder ROM/nonoperative

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TABLE 3 Range of Motion and Strengtha ASPBT Abduction Forward flexion External rotation, 0° External rotation, 90° Internal rotation, 90° Elbow flexion Elbow extension Forearm supination Forearm pronation Elbow flexion strength Elbow extension strength

94.4 95.9 94.6 92.1 95.2 97.2 99.4 98.0 99.1 91.1 91.8

6 6 6 6 6 6 6 6 6 6 6

12.1 9.4 10.7 11.3 7.8 6.4 2.5 5.9 2.2 11.7 10.0

OSPBT 98.1 98.1 99.4 96.9 94.5 99.4 99.6 100.0 100.0 100.0 100.0

6 6 6 6 6 6 6 6 6 6 6

3.2 3.6 9.9 7.2 7.2 2.5 1.5 3.1 1.1 13.0 14.0

P Value .299 .424 .283 .222 .810 .134 .693 .219 .089 .192 .119

a Values are reported as mean 6 SD and expressed as percentages of the nonoperative side. ASPBT, arthroscopic suprapectoral biceps tenodesis; OSPBT, open subpectoral biceps tenodesis.

shoulder ROM 3 100). Clinical examination results are reported in Table 3. No significant differences were noted in abduction (ASPBT: 94.4%; OSPBT: 98.1%; P = .299), forward flexion (ASPBT: 95.9%; OSPBT: 98.1%; P = .424), internal rotation (ASPBT: 95.2%; OSPBT: 94.5%; P = .810), external rotation (ASPBT: 92.1%-94.6%; OSPBT: 96.9%-99.4%; P = .222-.283), elbow flexion (ASPBT: 97.2%; OSPBT: 99.4%; P = .134), elbow extension (ASPBT: 99.4%; OSPBT: 99.6%; P = .693), forearm supination (ASPBT: 98.0%; OSPBT: 100.0%; P = .219), forearm pronation (ASPBT: 99.1%; OSPBT: 100.0%; P = .089), or elbow strength (ASPBT: 91.1%-91.8%; OSPBT: 100.0%; P = .119-.192) between the ASPBT and OSPBT cohorts. Few postoperative complications were encountered. The only significant complication noted in either cohort was postoperative stiffness. Patients were considered for intra-articular corticosteroid injections (1 mL Kenalog [triamcinolone] 40 [Bristol-Myers Squibb] with 3-5 mL of lidocaine without epinephrine) if they had a persistent range of motion deficit (\100° of forward flexion and abduction; \40° of internal or external rotation) past 8 weeks postoperatively. Three of the 32 patients with ASPBT had postoperative stiffness requiring injections, for a total complication rate of 9.4%. Three of 50 patients with OSPBT required injections for postoperative stiffness, representing a complication rate of 6.0%. All range of motion deficits had resolved by the study follow-up visits. No other complications were noted, including fractures, persistent pain, wound infections, deep venous thromboses, or known tenodesis failures.

DISCUSSION This is the first study to directly compare clinical outcomes of ASPBT and OSPBT techniques. No significant differences in clinical outcomes as determined by several validated outcome measures were found between the 2 tenodesis methods, nor were any range of motion or strength deficits noted at a minimum 2 years postoperatively.

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Despite being 2 of the most commonly utilized techniques for tenodesis, there are only a few studies that report clinical outcomes after ASPBT6,9,12,42,66,67 or OSPBT.4,5,44,50 Mazzocca et al44 published the most recent and comprehensive study on clinical outcomes after subpectoral biceps tenodesis with an interference screw, utilizing the same technique as presented in our study. A key disadvantage of the Mazzocca et al44 study is that patients with concomitant rotator cuff repair were included and composed over half (59%) of the final cohort, which makes the results more challenging to interpret. The authors reported the following results in the patients without concomitant rotator cuff repair: mean Constant-Murley score of 90.2, ASES score of 89.2, SST score of 10.6, and SANE score of 86.9%. We found remarkably similar results in our OSPBT cohort, with a mean Constant-Murley score of 91.8, ASES score of 88.4, SST score of 10.6, and SANE score of 86.8%. This validates our technique and outcomes with the currently published literature. Our present study examines a more homogeneous population by excluding patients with concomitant rotator cuff repair and also reports final range of motion and strength, which are 2 important advancements on the groundwork data reported by Mazzocca et al.44 Nho et al50 also reported clinical outcomes of a series of 13 patients who underwent open biceps tenodesis. All patients had concurrent arthroscopic repair of anterosuperior rotator cuff tears. The authors noted similar outcome scores to those in the present study and Mazzocca et al,44 with a postoperative ASES score of 89.6 and SST score of 10.7. The Nho et al50 study included complete postoperative scores, but again, it is challenging to ascertain whether the clinical improvement was because of rotator cuff repair, biceps tenodesis, or both. Even less data on clinical outcomes are available for ASPBT. Boileau et al9 reported a cohort of 15 patients who underwent arthroscopic biceps tenodesis performed with an interference screw for isolated type II SLAP lesions. In their tenodesis cohort, the final ConstantMurley score was 89, which is nearly the same as we found in our cohort of 27 patients (90.7) who underwent the same procedure for very similar indications. The authors did not report any other validated outcome measures or range of motion data. Scheibel et al67 found slightly lower Constant scores (75.0 and 78.3) in their study on comparative outcomes of 2 arthroscopic biceps tenodesis techniques; however, neither of their techniques utilized interference screw fixation, making comparison difficult. Lutton et al42 recently published a small series including clinical outcomes after ASPBT. In their 17 patients at a minimum 1-year follow-up, the final mean ASES score was 78, and the Constant-Murley score was 81. While these are slightly lower than the numbers that we report for a similar technique, it is important to note that 9 of the included 17 patients (53%) underwent concomitant rotator cuff repair, making it difficult to ascertain what effect that tenodesis imparted on the overall clinical improvement. To our knowledge, no previous studies have comprehensively evaluated postoperative upper extremity range of motion and strength after biceps tenodesis, nor have any

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compared these endpoints between the ASPBT and OSPBT techniques. In the early postoperative period, 9.4% of patients with ASPBT and 6.0% of patients with OSPBT had postoperative stiffness requiring management including further rehabilitation and/or intra-articular corticosteroid injections. This is slightly lower than reported incidences of early postoperative stiffness after biceps tenodesis (5.6%-17.9%) and reported rates of stiffness after rotator cuff repair (4.9%-18.6%).13,30,77 We found no significant differences between the ASPBT and OSPBT cohorts in shoulder range of motion, including abduction, forward flexion, internal rotation, and external rotation at a minimum 2-year follow-up. Similarly, no significant differences in final postoperative elbow range of motion and strength were found. In general, excellent range of motion and strength can be expected after either tenodesis technique for the described indications. Final shoulder range of motion was between 92.1% and 100.0% of the unaffected extremity, with the greatest deficits noted in external and internal rotations. Elbow flexion and extension were not significantly affected by the procedure, nor were forearm supination and pronation. The greatest deficits in elbow flexion and extension strength were noted in the ASPBT group, but these differences were not found to be statistically significant. This study has several notable strengths. It is the first study to directly compare clinical outcomes of ASPBT and OSPBT techniques. Second, it is the largest study on clinical outcomes of biceps tenodesis using these modern techniques. Third, the use of strict inclusion and exclusion criteria created a homogeneous study population and eliminated potential confounding variables that affected previous studies of similar techniques, most notably the exclusion of patients with concomitant rotator cuff repair. Fourth, a rigorous power analysis was utilized to calculate an adequate sample size to reduce the risk of type II errors. Lastly, this study includes a comprehensive evaluation of postoperative range of motion and strength, which is not reported in other studies. However, several study limitations must be acknowledged. The most notable limitation is the retrospective study design, with the typical biases associated with retrospective studies. No preoperative scores were collected, so it is not possible to quantify the amount of improvement that patients experienced. While the 2 techniques demonstrate similar clinical endpoints, the therapeutic effect of one may have been significantly greater than the other. In this instance, mistakenly accepting the null hypothesis that the techniques are equivalent would result in a type II error. The choice of arthroscopic or open biceps tenodesis was by surgeon preference and not randomized, which could add additional potential performance biases. Although the same surgeons performed both the arthroscopic and open tenodeses, some variation in technique could exist over the study period because of surgeon preference. Both arthroscopic and open tenodeses were performed with only interference screw fixation. Numerous other tenodesis methods including suture anchor and soft

tissue fixation methods exist, and no present literature has demonstrated the clinical superiority of any fixation technique. This limits the generalizability of the present study to surgeons who utilize fixation techniques other than interference screws. The study inclusion criteria yielded a homogeneous study population; however, excluding patients with concomitant rotator cuff repair weakens the external validity of the study findings, as only 23% of the available cohort of 363 patients met the inclusion criteria. Lastly, more than 1 examiner was utilized for study follow-up visits, although all examiners were clinicians with training in study procedures. To reduce the bias associated with this, all range of motion measurements were normalized to the nonoperative extremity, measured by the same examiner. Additionally, examiners were not blinded to the tenodesis method for each participant, as the presence or absence of an axillary incision was not concealed, which is another potential source of bias.

CONCLUSION Both ASPBT and OSPBT yield excellent clinical and functional results for the management of isolated superior labrum or LHB lesions. No significant differences in clinical outcomes as determined by several validated outcome measures were found between the 2 tenodesis methods, nor were any range of motion or strength deficits noted at a minimum 2 years postoperatively. Future prospective studies in which surgical techniques, implants, and positions of tenodesis are randomized and compared are necessary to fully validate these findings. Scan the QR code with your smartphone to view the In-Depth podcast associated with this article or visit http://ajsm.sagepub.com/site//misc/Index/ Podcasts.xhtml.

REFERENCES 1. Ahmad CS, ElAttrache NS. Arthroscopic biceps tenodesis. Orthop Clin North Am. 2003;34(4):499-506. 2. Ahrens PM, Boileau P. The long head of biceps and associated tendinopathy. J Bone Joint Surg Br. 2007;89(8):1001-1009. 3. Barber A, Field LD, Ryu R. Biceps tendon and superior labrum injuries: decision-marking. J Bone Joint Surg Am. 2007;89(8):1844-1855. 4. Becker DA, Cofield RH. Tenodesis of the long head of the biceps brachii for chronic bicipital tendinitis: long-term results. J Bone Joint Surg Am. 1989;71(3):376-381. 5. Berlemann U, Bayley I. Tenodesis of the long head of biceps brachii in the painful shoulder: improving results in the long term. J Shoulder Elbow Surg. 1995;4(6):429-435. 6. Boileau P, Baque F, Valerio L, et al. Isolated arthroscopic biceps tenotomy or tenodesis improves symptoms in patients with massive irreparable rotator cuff tears. J Bone Joint Surg Am. 2007;89(4):747757. 7. Boileau P, Krishnan SG, Coste JS, et al. Arthroscopic biceps tenodesis: a new technique using bioabsorbable interference screw fixation. Arthroscopy. 2002;18(9):1002-1012.

Downloaded from ajs.sagepub.com at MCGILL UNIVERSITY LIBRARY on March 17, 2015

Vol. 42, No. 11, 2014

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8. Boileau P, Neyton L. Arthroscopic tenodesis for lesions of the long head of the biceps. Oper Orthop Traumatol. 2005;17(6):601-623. 9. Boileau P, Parratte S, Chuinard C, et al. Arthroscopic treatment of isolated type II SLAP lesions: biceps tenodesis as an alternative to reinsertion. Am J Sports Med. 2009;37(5):929-936. 10. Busconi BB, DeAngelis N, Guerrero PE. The proximal biceps tendon: tricks and pearls. Sports Med Arthrosc. 2008;16(3):187-194. 11. Castagna A, Conti M, Mouhsine E, et al. Arthroscopic biceps tendon tenodesis: the anchorage technical note. Knee Surg Sports Traumatol Arthrosc. 2006;14(6):581-585. 12. Checchia SL, Doneux PS, Miyazaki AN, et al. Biceps tenodesis associated with arthroscopic repair of rotator cuff tears. J Shoulder Elbow Surg. 2005;14(2):138-144. 13. Chung SW, Huong CB, Kim SH, et al. Shoulder stiffness after rotator cuff repair: risk factors and influence on outcome. Arthroscopy. 2013;29(2):290-300. 14. Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res. 1987;214:160-164. 15. David TS, Schildhorn JC. Arthroscopic suprapectoral tenodesis of the long head biceps: reproducing an anatomic length-tension relationship. Arthrosc Tech. 2012;1(1):e127-e132. 16. Dines D, Warren RF, Inglis AE. Surgical treatment of lesions of the long head of the biceps. Clin Orthop Relat Res. 1982;164:165-171. 17. Elkousy HA, Fluhme DJ, O’Connor DP, et al. Arthroscopic biceps tenodesis using the percutaneous, intra-articular trans-tendon technique: preliminary results. Orthopedics. 2005;28(11):1316-1319. 18. Elser F, Braun S, Dewing CB, et al. Anatomy, function, injuries, and treatment of the long head of the biceps brachii tendon. Arthroscopy. 2011;27(4):581-592. 19. Franceschi F, Longo UG, Ruzzini L, et al. No advantages in repairing a type II superior labrum anterior and posterior (SLAP) lesion when associated with rotator cuff repair in patients over age 50: a randomized controlled trial. Am J Sports Med. 2008;36(2):247-253. 20. Franceschi F, Longo UG, Ruzzini L, et al. Soft tissue tenodesis of the long head of the biceps tendon associated to the Roman Bridge repair. BMC Musculoskelet Disord. 2008;9:78. 21. Froimson AI, O I. Keyhole tenodesis of biceps origin at the shoulder. Clin Orthop Relat Res. 1975;112:245-249. 22. Frost A, Zafar MS, Maffulli N. Tenotomy versus tenodesis in the management of pathologic lesions of the tendon of the long head of the biceps brachii. Am J Sports Med. 2009;37(4):828-833. 23. Gartsman GM, Hammerman SM. Arthroscopic biceps tenodesis: operative technique. Arthroscopy. 2000;16(5):550-552. 24. Gill TJ, McIrvin E, Mair SD, et al. Results of biceps tenotomy for treatment of pathology of the long head of the biceps brachii. J Shoulder Elbow Surg. 2001;10(3):247-249. 25. Godfrey J, Hamman R, Lowenstein S, et al. Reliability, validity, and responsiveness of the simple shoulder test: psychometric properties by age and injury type. J Shoulder Elbow Surg. 2007;16(3):260-267. 26. Golish SR, Caldwell PE 3rd, Miller MD, et al. Interference screw versus suture anchor fixation for subpectoral tenodesis of the proximal biceps tendon: a cadaveric study. Arthroscopy. 2008;24(10):11031108. 27. Hapa O, Gunay C, Komurcu E, et al. Biceps tenodesis with interference screw: cyclic testing of different techniques. Knee Surg Sports Traumatol Arthrosc. 2010;18(12):1779-1784. 28. Hitchcock HH, Bechtol CO. Painful shoulder; observations on the role of the tendon of the long head of the biceps brachii in its causation. J Bone Joint Surg Am. 1948;30(2):263-273. 29. Hsu AR, Ghodadra NS, Provencher MT, et al. Biceps tenotomy versus tenodesis: a review of clinical outcomes and biomechanical results. J Shoulder Elbow Surg. 2011;20(2):326-332. 30. Huberty DP, Schoolfield JD, Brady PC, et al. Incidence and treatment of postoperative stiffness following arthroscopic rotator cuff repair. Arthroscopy. 2009;25(8):880-890. 31. Jarrett CD, McClelland WB Jr, Xerogeanes JW. Minimally invasive proximal biceps tenodesis: an anatomical study for optimal placement and safe surgical technique. J Shoulder Elbow Surg. 2011;20(3):477-480.

2589

32. Jayamoorthy T, Field JR, Costi JJ, et al. Biceps tenodesis: a biomechanical study of fixation methods. J Shoulder Elbow Surg. 2004; 13(2):160-164. 33. Kazis LE, Miller DR, Clark JA, et al. Improving the response choices on the veterans SF-36 health survey role functioning scales: results from the Veterans Health Study. J Ambul Care Manage. 2004;27(3):263-280. 34. Kazis LE, Miller DR, Skinner KM, et al. Patient-reported measures of health: the Veterans Health Study. J Ambul Care Manage. 2004;27(1):70-83. 35. Kelly AM, Drakos MC, Fealy S, et al. Arthroscopic release of the long head of the biceps tendon: functional outcome and clinical results. Am J Sports Med. 2005;33(2):208-213. 36. Kim SH, Yoo JC. Arthroscopic biceps tenodesis using interference screw: end-tunnel technique. Arthroscopy. 2005;21(11):1405. 37. Kirkley A, Griffin S, Dainty K. Scoring systems for the functional assessment of the shoulder. Arthroscopy. 2003;19(10):1109-1120. 38. Klepps S, Hazrati Y, Flatow E. Arthroscopic biceps tenodesis. Arthroscopy. 2002;18(9):1040-1045. 39. Koh KH, Ahn JH, Kim SM, et al. Treatment of biceps tendon lesions in the setting of rotator cuff tears: prospective cohort study of tenotomy versus tenodesis. Am J Sports Med. 2010;38(8):1584-1590. 40. Lafosse L, Shah AA, Butler RB, et al. Arthroscopic biceps tenodesis to supraspinatus tendon: technical note. Am J Orthop (Belle Mead NJ). 2011;40(7):345-347. 41. Lo IK, Burkhart SS. Arthroscopic biceps tenodesis using a bioabsorbable interference screw. Arthroscopy. 2004;20(1):85-95. 42. Lutton DM, Gruson KI, Harrison AK, et al. Where to tenodese the biceps: proximal or distal? Clin Orthop Relat Res. 2011;469(4):1050-1055. 43. Mazzocca AD, Bicos J, Santangelo S, et al. The biomechanical evaluation of four fixation techniques for proximal biceps tenodesis. Arthroscopy. 2005;21(11):1296-1306. 44. Mazzocca AD, Cote MP, Arciero CL, et al. Clinical outcomes after subpectoral biceps tenodesis with an interference screw. Am J Sports Med. 2008;36(10):1922-1929. 45. Mazzocca AD, Rios CG, Romeo AA, et al. Subpectoral biceps tenodesis with interference screw fixation. Arthroscopy. 2005;21(7):896. 46. Michele AA, Krueger FJ. Tenodesis of biceps tendons; a preliminary report. Surgery. 1951;29(4):555-559. 47. Michener LA, McClure PW, Sennett BJ. American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, patient self-report section: reliability, validity, and responsiveness. J Shoulder Elbow Surg. 2002;11(6):587-594. 48. Millett PJ, Sanders B, Gobezie R, et al. Interference screw vs. suture anchor fixation for open subpectoral biceps tenodesis: does it matter? BMC Musculoskelet Disord. 2008;9:121. 49. Moros C, Levine WN, Ahmad CS. Suture anchor and percutaneous intra-articular transtendon biceps tenodesis. Sports Med Arthrosc. 2008;16(3):177-179. 50. Nho SJ, Frank RM, Reiff SN, et al. Arthroscopic repair of anterosuperior rotator cuff tears combined with open biceps tenodesis. Arthroscopy. 2010;26(12):1667-1674. 51. Nho SJ, Reiff SN, Verma NN, et al. Complications associated with subpectoral biceps tenodesis: low rates of incidence following surgery. J Shoulder Elbow Surg. 2010;19(5):764-768. 52. Nho SJ, Strauss EJ, Lenart BA, et al. Long head of the biceps tendinopathy: diagnosis and management. J Am Acad Orthop Surg. 2010;18(11):645-656. 53. Nord KD, Smith GB, Mauck BM. Arthroscopic biceps tenodesis using suture anchors through the subclavian portal. Arthroscopy. 2005;21(2):248-252. 54. Oh JH, Jo KH, Kim WS, et al. Comparative evaluation of the measurement properties of various shoulder outcome instruments. Am J Sports Med. 2009;37(6):1161-1168. 55. Osbahr DC, Diamond AB, Speer KP. The cosmetic appearance of the biceps muscle after long-head tenotomy versus tenodesis. Arthroscopy. 2002;18(5):483-487. 56. Ozalay M, Akpinar S, Karaeminogullari O, et al. Mechanical strength of four different biceps tenodesis techniques. Arthroscopy. 2005;21(8):992-998.

Downloaded from ajs.sagepub.com at MCGILL UNIVERSITY LIBRARY on March 17, 2015

2590 Werner et al

The American Journal of Sports Medicine

57. Papp DF, Skelley NW, Sutter EG, et al. Biomechanical evaluation of open suture anchor fixation versus interference screw for biceps tenodesis. Orthopedics. 2011;34(7):e275-e278. 58. Patzer T, Rundic JM, Bobrowitsch E, et al. Biomechanical comparison of arthroscopically performable techniques for suprapectoral biceps tenodesis. Arthroscopy. 2011;27(8):1036-1047. 59. Patzer T, Santo G, Olender GD, et al. Suprapectoral or subpectoral position for biceps tenodesis: biomechanical comparison of four different techniques in both positions. J Shoulder Elbow Surg. 2012;21(1):116-125. 60. Pinzur MS, Hopkins GE. Biceps tenodesis for painful inferior subluxation of the shoulder in adult acquired hemiplegia. Clin Orthop Relat Res. 1986;206:100-103. 61. Provencher MT, Frank RM, Macian D, et al. An analysis of shoulder outcomes scores in 275 consecutive patients: disease-specific correlation across multiple shoulder conditions. Mil Med. 2012;177(8):975-982. 62. Provencher MT, LeClere LE, Romeo AA. Subpectoral biceps tenodesis. Sports Med Arthrosc. 2008;16(3):170-176. 63. Richards DP, Burkhart SS. Arthroscopic-assisted biceps tenodesis for ruptures of the long head of biceps brachii: the cobra procedure. Arthroscopy. 2004;20(Suppl 2):201-207. 64. Richards DP, Burkhart SS. A biomechanical analysis of two biceps tenodesis fixation techniques. Arthroscopy. 2005;21(7):861-866. 65. Romeo AA, Mazzocca AD, Tauro JC. Arthroscopic biceps tenodesis. Arthroscopy. 2004;20(2):206-213. 66. Sanders B, Lavery KP, Pennington S, et al. Clinical success of biceps tenodesis with and without release of the transverse humeral ligament. J Shoulder Elbow Surg. 2012;21(1):66-71. 67. Scheibel M, Schroder RJ, Chen J, et al. Arthroscopic soft tissue tenodesis versus bony fixation anchor tenodesis of the long head of the biceps tendon. Am J Sports Med. 2011;39(5):1046-1052. 68. Sekiya JK, Elkousy HA, Rodosky MW. Arthroscopic biceps tenodesis using the percutaneous intra-articular transtendon technique. Arthroscopy. 2003;19(10):1137-1141. 69. Shank JR, Singleton SB, Braun S, et al. A comparison of forearm supination and elbow flexion strength in patients with long head of the biceps tenotomy or tenodesis. Arthroscopy. 2011;27(1):9-16. 70. Skare O, Schroder CP, Reikeras O, et al. Efficacy of labral repair, biceps tenodesis, and diagnostic arthroscopy for SLAP lesions of

71.

72. 73.

74.

75. 76.

77.

78. 79.

80.

81.

82.

the shoulder: a randomised controlled trial. BMC Musculoskelet Disord. 2010;11:228. Slabaugh MA, Frank RM, Van Thiel GS, et al. Biceps tenodesis with interference screw fixation: a biomechanical comparison of screw length and diameter. Arthroscopy. 2011;27(2):161-166. Slenker NR, Lawson K, Ciccotti MG, et al. Biceps tenotomy versus tenodesis: clinical outcomes. Arthroscopy. 2012;28(4):576-582. Tangari M, Carbone S, Gallo M, et al. Long head of the biceps tendon rupture in professional wrestlers: treatment with a mini-open tenodesis. J Shoulder Elbow Surg. 2011;20(3):409-413. Tashjian RZ, Deloach J, Green A, et al. Minimal clinically important differences in ASES and simple shoulder test scores after nonoperative treatment of rotator cuff disease. J Bone Joint Surg Am. 2010;92(2):296-303. Verma NN, Drakos M, O’Brien SJ. Arthroscopic transfer of the long head biceps to the conjoint tendon. Arthroscopy. 2005;21(6):764. Walch G, Edwards TB, Boulahia A, et al. Arthroscopic tenotomy of the long head of the biceps in the treatment of rotator cuff tears: clinical and radiographic results of 307 cases. J Shoulder Elbow Surg. 2005;14(3):238-246. Werner BC, Pehlivan HC, Hart JM, et al. Increased incidence of postoperative stiffness after arthroscopic compared with open biceps tenodesis [published online May 22, 2014]. Arthroscopy. doi:10.1016/j.arthro.2014.03.024. Wiley WB, Meyers JF, Weber SC, et al. Arthroscopic assisted mini-open biceps tenodesis: surgical technique. Arthroscopy. 2004;20(4):444-446. Williams GN, Gangel TJ, Arciero RA, et al. Comparison of the Single Assessment Numeric Evaluation method and two shoulder rating scales: outcomes measures after shoulder surgery. Am J Sports Med. 1999;27(2):214-221. Wittstein JR, Queen R, Abbey A, et al. Isokinetic strength, endurance, and subjective outcomes after biceps tenotomy versus tenodesis: a postoperative study. Am J Sports Med. 2011;39(4):857-865. Wolf RS, Zheng N, Weichel D. Long head biceps tenotomy versus tenodesis: a cadaveric biomechanical analysis. Arthroscopy. 2005;21(2):182-185. Zhang AL, Kreulen C, Ngo SS, et al. Demographic trends in arthroscopic SLAP repair in the United States. Am J Sports Med. 2012;40(5):1144-1147.

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