J Shoulder Elbow Surg (2015) 24, e279-e285
www.elsevier.com/locate/ymse
Demographic trends in arthroscopic and open biceps tenodesis across the United States Evan E. Vellios, MDa, Alireza K. Nazemi, MSb, Michael G. Yeranosian, MDa, Jeremiah R. Cohen, BSa, Jeffrey C. Wang, MDc, David R. McAllister, MDa, Frank A. Petrigliano, MDa,* a
Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA Department of Bioengineering, UCLA, Los Angeles, CA, USA c Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA, USA b
Background: The purpose of this study was to evaluate trends in procedures and to report on demographic data of patients undergoing arthroscopic vs. open biceps tenodesis. Methods: A retrospective review of a commercially available database (PearlDiver) was conducted to identify cases of arthroscopic and open biceps tenodesis performed between 2007 and 2011 with concurrent diagnoses of commonly associated shoulder disorders. Each record provided the patient’s age, gender, and region within the United States, and statistical significance was determined with respect to each of these demographics. Results: There were 9011 patients who underwent arthroscopic biceps tenodesis and 11,678 patients who underwent open biceps tenodesis between 2007 and 2011. The number of biceps tenodesis cases increased from 2007 to 2011 (2047 to 5832; P ¼ .015). Both arthroscopic and open biceps tenodesis procedures were performed most commonly in the 30- to 59-year-old age group (76.3% and 76.1%; P < .00001). Men underwent arthroscopic or open biceps tenodesis more commonly than women did (66.1% and 71.9%; P < .00001). Rates of both open and arthroscopic biceps tenodesis varied significantly among the Midwest, South, Northeast, and West regions (P ¼ .009; P ¼ .007); 49.8% of arthroscopic and 44.6% of open biceps tenodesis cases were associated with rotator cuff tears, whereas 14.4% of arthroscopic and 16.2% of open cases were associated with biceps tendon disorders. Conclusion: Both arthroscopic and open biceps tenodesis cases increased annually from 2007 to 2011. The majority of biceps tenodesis cases were performed in men aged 30 to 59 years, and the South had the highest overall number of cases. Further studies are required to evaluate the efficacy of these procedures with and without concomitant pathologic processes. Level of evidence: Epidemiology Study, Large Database Analysis. Ó 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. Keywords: Arthroscopic; open; biceps tenodesis; demographics; retrospective
Institutional Review Board approval was not required for this study. *Reprint requests: Frank A. Petrigliano, MD, Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, #33-55 PVUB, 10945 Le Conte Ave, Los Angeles, CA 90095, USA. E-mail address: [email protected] (F.A. Petrigliano).
Anterior shoulder pain and loss of forward flexion are common symptoms of lesions related to the long head of the biceps brachii (LHB).13 The anatomy of this region causes it to often be affected by disease of the rotator cuff
1058-2746/$ - see front matter Ó 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2015.04.021
e280 (RTC) and subacromial space.1,2,12,13,21,25 Previous studies have shown that close to 90% of patients with biceps tendinitis suffer from concomitant RTC or superior labral anterior-posterior (SLAP) tears, especially in the dominant upper extremity.5,11,17 The two most common surgical treatments for lesions of the LHB are tenotomy and tenodesis, with some studies suggesting that tenodesis provides a lower incidence of weakness, biceps discomfort, and cosmetic deformity.1,11,24,27 Tenodesis is performed most commonly to treat a partial-thickness tear of >50% diameter or a medial subluxation of the tendon in association with an RTC tear.14,21,25 Whereas tenodesis has historically been performed through an open approach, arthroscopic methods have become more popular as novel instrumentation has facilitated the ease of this procedure.26 The purpose of this study was to evaluate the trends in procedures, to report on the demographic and regional data of patients undergoing arthroscopic vs. open biceps tenodesis, and to describe the concomitant shoulder disorders commonly associated with the contemporary utilization of biceps tenodesis.
E.E. Vellios et al. Table I Age breakdown of arthroscopic and open tenodesis cases, 2007-2011 Age group (years)
Arthroscopic cases
Open cases
0-29 30-59 >60 Total
195 6876 1940 9011
329 8884 2465 11,678
(2.2%) (76.3%) (21.5%) (100%)
(2.8%) (76.1%) (21.1%) (100%)
Poisson regression analysis: P < .00001. The difference in the performance of arthroscopic and open biceps tenodesis was statistically significant for each of the 3 age groups.
Bonferroni adjustment was used to determine the significance of differences in the performance of arthroscopic and open biceps tenodesis in relation to the primary diagnosis coded. Eight of the 20 primary diagnosis codes used in this study were incorporated into this analysis (Appendix). Significance level was set at P < .05.
Results Materials and methods A retrospective review of the PearlDiver patient records database (www.pearldiverinc.com; PearlDiver, Inc., Fort Wayne, IN, USA) was performed. This is a commercially available database searchable by both Current Procedural Terminology (CPT) and International Classification of Diseases, Ninth Revision (ICD-9) codes. It contains records for approximately 20 million patients with orthopedic diagnoses obtained from an insurance company, United Healthcare (Decatur, IL, USA). The database was queried for all cases of arthroscopic biceps tenodesis (CPT-29828) and open biceps tenodesis (CPT-23430, CPT-23440) that were performed between 2007 and 2011 with concurrent diagnoses of commonly associated shoulder disorders (Appendix). The codes were searched to exclude the same code’s being counted more than once for the same patient (see Appendix for complete CPT and ICD-9 code descriptions). Each record provided the patient’s age, gender, and region within the United States. In reporting results, percentages of arthroscopic or open tenodesis were calculated from the total number of cases performed during the specified time interval and categorized according to year, gender, age group, and region.33 Furthermore, the percentage of individuals undergoing arthroscopic or open biceps tenodesis with their associated primary diagnosis was determined and again stratified according to year, gender, age group, and region.
Statistical analysis For statistical analysis, patients were categorized into 3 age groups: 0 to 29 years, 30 to 59 years, and >60 years. c2 analysis was used to assess the statistical significance of variations between regions. Poisson regression analysis was used to determine statistical significance of variations between age groups and genders. Linear regression was used to determine the significance of differences in the data from year to year. Binomial analysis with
Arthroscopic tenodesis A total of 9011 patients underwent arthroscopic biceps tenodesis between 2007 and 2011. Arthroscopic tenodesis was most common in the 30- to 59-year-old age group (Table I). Approximately two thirds of the total patients undergoing arthroscopic tenodesis between 2008 and 2011 were men and one third were women (P < .00001; Table II). Of the cases of arthroscopic tenodesis, 23.7% were performed in the Midwest region, 9.8% in the Northeast region, 50.2% in the South region, and 16.3% in the West region (Fig. 1). The differences in these percentages were statistically significant compared with one another (P ¼ .009). From 2007 to 2011, the percentage of total cases of biceps tenodesis performed arthroscopically increased from 0.15% to 48.5% (P < .00001; Table III). Furthermore, the overall number of cases of arthroscopic biceps tenodesis increased annually from 3 in 2007 to 2831 in 2011 (Table III and Fig. 2).
Open tenodesis A total of 11,678 patients underwent open biceps tenodesis between 2007 and 2011. The age stratification for patients undergoing open tenodesis was as follows: 2.8% in the 0- to 29-year age group, 76.1% in the 30- to 59-year age group, and 21.1% in the >60-year age group (Table I). Of the total patients undergoing open tenodesis, 71.9% were male and 28.1% were female (P < .0001; Table IV). Of the cases of open tenodesis, 25.5% were performed in the Midwest region, 9.2% in the Northeast region, 43.5% in the South region, and 21.8% in the West region (Table V). These
Demographic trends in biceps tenodesis procedures Table II
e281
Arthroscopic tenodesis gender breakdown
Gender 2007
2008
2009
2010
2011
Total
Male 66.6% (2/3) 66.7% (1115/1670) 66.6% (1416/2125) 66.2% (1578/2382) 65.4% (1852/2831) 66.1% (5963/9011) Female 33.3% (1/3) 1 33.3% (555/1678) 33.4% (709/2137) 33.8% (804/2394) 34.6% (979/2846) 33.9% (3048/9011) 100% (3/3) 100% (1670/1670) 100% (2125/2125) 100% (2382/2382) 100% (2831/2831) 100% (9011/9011) Poisson regression analysis: P < .00001. This table shows that for every year included in the analysis, except 2007, men and women received a significantly different number of arthroscopic tenodesis procedures.
Figure 1 Arthroscopic tenodesis geographic trends. A statistically significant difference was noted in comparing the total number of arthroscopic cases in each region with one another (P ¼ .009).
percentages were statistically significant compared with one another (P ¼ .0070). From 2007 to 2011, the percentage of cases of biceps tenodesis performed through an open approach decreased from 99.85% to 56.5% (P < .00001; Table III). However, the total number of cases of open biceps tenodesis increased annually from 2044 in 2007 to 3001 in 2011, with no statistically significant difference between years noted (P ¼ .106). Moreover, the total number of cases of biceps tenodesis has increased from 2047 in 2007 to 5832 in 2011 (P ¼ .015). An analysis comparing open with arthroscopic biceps tenodesis showed that for the years 2007, 2008, and 2011, there was a statistically significant difference in the number of people undergoing each procedure (P < .00001; Table III). Furthermore, comparing the total number of procedures for open and arthroscopic tenodesis by age group also showed a statistically significant difference (P < .00001; Table I).
Arthroscopic vs. open tenodesis and concomitant shoulder disorders Of the 20 ICD-9 codes cross-referenced in this study, the most common diagnoses associated with both open and arthroscopic tenodesis were 719.41 (pain in joint, shoulder), 840.4 (RTC sprain), 726.10 (RTC syndrome unspecified), 727.61 (RTC rupture), 840.6 (supraspinatus sprain), and 726.2 (other affections of shoulder region, not elsewhere classified) (Table VI). Certain cases were
associated with disorders of the biceps tendon. These included 14.4% of arthroscopic and 16.2% of open biceps tenodesis cases associated with biceps tenosynovitis (762.12) and 5.6% of arthroscopic and 9.3% of open tenodesis cases associated with biceps tendon rupture (727.62). Furthermore, 49.8% of arthroscopic and 44.6% of open tenodesis cases were associated with unspecified RTC disease (726.10), whereas 8.3% of arthroscopic and 6.6% of open tenodesis cases were associated with adhesive capsulitis (726.0). Finally, 4.4% of arthroscopic and 3.8% of open tenodesis cases were associated with calcific tendinitis (726.11), and 16.1% of arthroscopic and 14.5% of open tenodesis cases were associated with superior glenoid labrum lesions (840.7). All ICD-9 codes used in this study overlapped with CPT codes used for arthroscopic and open biceps tenodesis (Appendix).
Discussion The purpose of this study was to report on current trends in the utilization of arthroscopic and open biceps tenodesis; to demonstrate the association of these 2 procedures with concomitant shoulder disorders; and to comment on demographic data, such as age, region, and gender, of the corresponding patients. The data demonstrated an increase in the utilization of arthroscopic tenodesis from 2007 to 2011 compared with a smaller yearly increase in the overall performance of open biceps tenodesis during this same interval (P < .00001). Moreover, cases of arthroscopic and open biceps tenodesis combined have increased from 2047 in 2007 to 5832 in 2011 (P ¼ .015; Fig. 2). The increased utilization of both arthroscopic and open biceps tenodesis in our study may reflect a heightened awareness of biceps tendon disease, preference of the patient and surgeon to avoid the potential morbidity of tenotomy, and improved surgical instrumentation available for arthroscopic tenodesis. Previous studies have favored an arthroscopic suprapectoral approach because of its smaller surgical dissection, ease of revision, and shorter operative times, whereas others have advocated an open subpectoral approach because of its distal tenodesis site and ability to easily re-establish the length-tension relationship of the LHB with infrequent postoperative intertubercular sulcus pain.10,15,23 Furthermore, considerable controversy remains
48.5% (2831/5832) 51.5% (3001/5832) 100% (5832/5832) Poisson regression analysis: P < .00001 (for 2007, 2008, and 2011).
2011 2010
49.8% (2380/4773) 50.2% (2393/4773) 100% (4773/4773) 49.4% (2128/4289) 50.6% (2161/4289) 100% (4289/4289)
2009 2008
44.5% (1669/3748) 55.5% (2079/3748) 100% (3748/3748) 0.15% (3/2047) 99.85% (2044/2047) 100% (2047/2047)
2007
Percentage of arthroscopic vs. open tenodesis cases per year Table III
Arthroscopic cases per year Open cases per year
2007-2011
E.E. Vellios et al. 43.5% (9011/20,689) 56.5% (11,678/20,689) 100% (20,689/20,689)
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regarding the optimal tenodesis fixation method; some authors advocate soft tissue fixation to structures of the rotator interval, whereas others advocate bone fixation with suture anchors or interference screws.4,7,10,15,22,23,26 Further studies are needed to determine whether this observed increase in the performance of biceps tenodesis reflects an evolution in the surgical management of chronic shoulder pain and LHB disease. Regardless, it seems that biceps tenodesis is becoming an ever-increasing treatment modality for disorders of the RTC and biceps tendon. Our data demonstrate a strong association between the performance of biceps tenodesis and injuries to structures other than the biceps tendon. In fact, in cases of both arthroscopic and open tenodesis, RTC disorders were by far the most commonly recorded primary diagnoses. This is supported by multiple studies demonstrating both macroscopic and microscopic LHB tendinopathy in the setting of chronic RTC tears.3,32 In fact, a study by Walch et al consisting of 307 patients with nonoperable full-thickness RTC tears demonstrated that biceps tenotomy alone resulted in considerable improvement in 87% of patients with an average follow-up of 57 months.29 Although Walch’s study involved biceps tenotomy, it is plausible that a similar response could be seen in cases of biceps tenodesis. Numerous studies have shown that many shoulder diagnoses coexist with biceps tendonitis. In fact, Walker-Bone et al in a 2-stage cross-sectional study of upper extremity musculoskeletal injuries in the United Kingdom showed that in 28 shoulders with diagnosed biceps tendinitis, 16 fulfilled criteria for RTC tendinitis and 23 for adhesive capsulitis as well.30 As individuals age, they continue to acquire degenerative changes over time, leading to distortion of the normal shoulder anatomy, as demonstrated by Clement et al in a 2012 review stating that up to 54% of people older than 65 years have partial or complete tears of the RTC seen on magnetic resonance imaging.9 Although no comparable studies have been performed looking specifically at LHB disease, it is likely that an analogous trend exists. More important, our study demonstrates a statistically significant difference in the performance of arthroscopic vs. open tenodesis in 1-on-1 comparisons of different primary diagnoses (Table VII). For example, primary diagnoses involving structures of the RTC and superior glenoid labrum were more likely to be repaired arthroscopically, whereas primary diagnoses involving the biceps tendon were more likely to be repaired by an open approach. This may be due to the fact that arthroscopic RTC repair is the current ‘‘gold standard,’’ and some surgeons may also opt to repair the biceps tendon or SLAP tear if they have already committed to performing the RTC repair in this manner vs. performing a separate open procedure.3 Currently, no consensus for treatment of SLAP lesions or isolated biceps tendon disorders specifically has been reached, and treatments vary between arthroscopic repair, tendon tenotomy, biceps tenodesis, and debridement.6,7,31,33 In a number of recent studies, the
Demographic trends in biceps tenodesis procedures
Figure 2 Annual trend for arthroscopic, open, and total cases of biceps tenodesis. Poisson regression analysis: P < .00001.
addition of biceps tenodesis in the setting of RTC repair had equivocal effect on the subjective outcomes when performed and in comparison to tenotomy.18,20 Therefore, the forces driving the increased utilization of tenodesis are uncertain. Furthermore, the increased use of arthroscopic tenodesis in the absence of data suggesting it is more effective, faster, or less expensive should be noted. This is clearly an area for further research. Both arthroscopic and open biceps tenodesis procedures were performed most commonly in the 30- to 59-year-old age group, representing 76.3% and 76.1% of the total cases, respectively. This likely reflects the notion that tenodesis is the preferred surgical treatment for refractory biceps tendinitis in young, manually active patients because it maintains the natural length-tension relationship of the biceps muscle, allows greater elbow flexion and forearm supination strength postoperatively, and does not result in cosmetic deformity.1,11,24 The percentages of cases across the different age groups were equivalent between arthroscopic and open tenodesis. Individuals in the >60-year-old group had the second highest percentages of both arthroscopic and open tenodesis cases, but the majority of those cases occurred in those younger than 70 years. This is most likely because biceps tenotomy is recommended for older patients with sedentary lifestyles, low demands for future physical activity, and lack of concern for cosmetic appearance.11,12,21,25 Furthermore, tenotomy has the apparent advantages of being simple and quick, with less associated immobilization and rehabilitation time than for tenodesis.12 Given that the majority of patients undergoing arthroscopic and open tenodesis are older than 30 years, it is likely that the number of surgical cases will continue to increase as the population continues to age. Unfortunately, a comparative analysis for biceps tenotomy is not possible as no CPT code exists for arthroscopic tenotomy. Even if biceps tenotomy data were available, it would not change the fact that the overall performance of biceps tenodesis increased from 2007 to 2011; however, having those data would allow us to make
e283 additional meaningful statements with regard to surgical practice and surgeon preference in different regions of the United States. Interestingly, there was a significant difference in gender distribution among individuals undergoing both arthroscopic and open tenodesis, with a male to female ratio of roughly 2:1. This male predominance possibly reflects differences in physical demands placed on individuals by their respective occupations. van Rijn et al showed in their systematic review that shoulder pain was positively associated with employment that required forceful exertion and high degrees of repetition, such as that seen in industrial workers, ship welders, and butchers.28 This correlation between predominantly male occupations and shoulder injuries might help account for the considerable difference in the performance of tenodesis between men and women. Furthermore, it can be postulated that this gender discrepancy would not be seen in individuals undergoing tenotomy. Multiple studies have shown that women are less likely to suffer from a Popeye deformity than are men, making tenotomy a more appealing surgical option for women with biceps disease or chronic shoulder pain.8,16 In fact, a study by Lim et al to demonstrate patient-related risk factors for complications after tenotomy showed that of 216 patients undergoing tenotomy, 138 (64%) were female.20 Future demographic studies taking into consideration occupation and lifestyle are needed to further elucidate the cause of this discrepancy. The differences in the performance of both arthroscopic and open biceps tenodesis across the 4 regions in our study were statistically significant, with the highest percentage of both procedures occurring in the South. Possible explanations for this finding include differences in surgeon preference (i.e., surgeons in the South region may prefer biceps tenodesis over tenotomy) or patient preference (due to concerns about cosmetic appearance or possible exertional limitations), but these conclusions are difficult to make without data on biceps tenotomy. It is more likely that some of the regional differences found in our study can be attributed to pre-existing differences in the baseline patient population from which our data were drawn as 9,799,730 or 48% of the 20,484,172 patients in the PearlDiver database reside in the South. This selection bias is likely due to the distribution of patients carrying the United Healthcare group insurance plan from which the database is derived, thus making it not a true cross section of the U.S. population. Furthermore, in comparing the performance of arthroscopic and open biceps tenodesis, regional differences were minimal across all 4 regions (23.7% arthroscopic vs. 25.5% open in the Midwest, 9.2% arthroscopic vs. 9.8% open in the Northeast, 43.5% arthroscopic vs. 50.2% open in the South, and 16.3% arthroscopic vs. 21.8% open in the West). A major limitation of our study was the limited number of cases of arthroscopic biceps tenodesis coded for in 2007.
e284 It is unlikely that only 3 cases of arthroscopic biceps tenodesis were performed during this period, given that the following year showed a dramatic increase by >1500 cases. It is possible that this is partly due to an error in coding, in which arthroscopic biceps tenodesis was categorized under an incorrect CPT code by the primary surgeon, given that a CPT code for arthroscopic biceps tenodesis did not exist until late 2007. In addition, our study population was drawn from a database containing only individuals insured through a private health insurance company, United Healthcare, therefore excluding those patients who are uninsured or insured through Medicare or another private health insurance provider. As a result, it is possible that our study underestimates the overall number of both arthroscopic and open biceps tenodesis cases, especially given that the second highest performance for both procedures occurred in the >60-year age group. Moreover, we were unable (1) to determine if the operative procedures were performed on the dominant vs. nondominant arm, (2) to distinguish between the types of tenodesis techniques and fixations, (3) to determine whether a shoulder specialist or a general orthopedic surgeon performed each operation, or (4) to compare clinical outcomes based on different surgical techniques. Unfortunately, an inherent limitation of database studies such as this is the inability to examine clinical outcomes as only demographic data (including age, gender, and region), CPT codes, and ICD-9 codes are recorded, and there is no way of identifying or contacting individual patients in the database. Taking these factors into consideration is a major goal of further research in this area. Even with these limitations, we believe that this study portrays valuable data with regard to the demographic trends in the performance of biceps tenodesis in the United States.
Conclusion Our analysis indicates that the utilization of both arthroscopic and open biceps tenodesis in the United States is increasing on a yearly basis. Overall, open tenodesis appears to be a more common procedure than arthroscopic tenodesis, but arthroscopic tenodesis has shown a significantly larger increase in performance from 2007 to 2011 despite any contemporary evidence of its superiority. The performance of both arthroscopic and open biceps tenodesis appears to be highest in people aged 30 to 59 years, with both procedures being >2 times more common in men than in women. The performance of arthroscopic and open biceps tenodesis showed relatively equal distributions across the Midwest, Northeast, South, and West regions, with the South having the highest number of tenodesis cases overall. Both arthroscopic and open biceps tenodesis were performed more commonly in association with
E.E. Vellios et al. disease of the RTC than the biceps tendon despite recent literature to suggest it may or may not improve outcomes in this population.18,19 Future studies are needed to compare the clinical efficacy of open vs. arthroscopic tenodesis and their effectiveness in comparison to simple tenotomy.
Acknowledgment The authors thank members of the UCLA Statistical Consulting Group for their generous help.
Disclaimer The authors, their immediate families, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
Supplementary data Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.jse.2015.04.021.
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e285 21. Lo I, Burkhart SS. Arthroscopic biceps tenodesis: indications and technique. Oper Tech Sports Med 2002;10:105-12. http://dx.doi.org/ 10.1053/otsm.2002.30651 22. Mazzocca AD, Rios CG, Romeo AA, Arciero RA. Subpectoral biceps tenodesis with interference screw fixation. Arthroscopy 2005;21:896. e1-e7. http://dx.doi.org/10.1016/j.arthro.2005.04.002 23. Nho SJ, Reiff SN, Verma NN, Slabaugh MA, Mazzocca AD, Romeo AA. Complications associated with subpectoral biceps tenodesis: low rates of incidence following surgery. J Shoulder Elbow Surg 2010;19:764-8. http://dx.doi.org/10.1016/j.jse.2010.01.024 24. Osbahr DC, Diamond AB, Speer KP. The cosmetic appearance of the biceps muscle after long-head tenotomy versus tenodesis. Arthroscopy 2002;18:483-7. http://dx.doi.org/10.1053/jars.2002.32233 25. Richards DP, Burkhart SS, Lo I. Arthroscopic biceps tenodesis with interference screw fixation: the lateral decubitus position. Oper Tech Sports Med 2003;11:15-23. http://dx.doi.org/10.1053/otsm.2003.35893 26. Romeo AA, Mazzocca AD, Tauro JC. Arthroscopic biceps tenodesis. Arthroscopy 2004;2:206-13. http://dx.doi.org/10.1016/j.arthro.2003. 11.033 27. Slenker NR, Lawson K, Ciccotti MG, Dodson CC, Cohen SB. Biceps tenotomy versus tenodesis: clinical outcomes. Arthroscopy 2012;28: 576-82. http://dx.doi.org/10.1016/j.arthro.2011.10.017 28. van Rijn RM, Huisstede BMA, Koes B, Burdorf A. Associations between work-related factors and specific disorders of the shoulderda systematic review of the literature. Scand J Work Environ Health 2010;36:189-201. http://dx.doi.org/10.5271/sjweh.2895 29. Walch G, Edwards TB, Boulahia A, Nove-Josserand L, Neyton L, Szabo I. 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;14:238-46. http://dx.doi.org/10. 1016/j.jse.2004.07.008 30. Walker-Bone K, Palmer KT, Reading I, Coggon D, Cooper C. Prevalence and impact of musculoskeletal disorders of the upper limb in the general population. Arthritis Care Res 2004;51:642-51. http:// dx.doi.org/10.1002/art.20535 31. Weber SC, Martin DF, Seiler JG III, Harrast JJ. Superior labrum anterior and posterior lesions of the shoulder: incidence rates, complications, and outcomes as reported by American Board of Orthopedic Surgery. Part II candidates. Am J Sports Med 2012;40: 1538-43. http://dx.doi.org/10.1177/0363546512447785 32. Wu PT, Jou IM, Yang CC, Lin CJ, Yang CY, Su FC, et al. The severity of the long head biceps tendinopathy in patients with chronic rotator cuff tears: macroscopic versus microscopic results. J Shoulder Elbow Surg 2014;23:1099-106. http://dx.doi.org/10.1016/j.jse.2013.11.013 33. Zhang AL, Kreulen C, Ngo SS, Hame SL, Wang JC, Gamradt SC. Demographic trends in arthroscopic SLAP repair in the United States. Am J Sports Med 2012;40:1144-7. http://dx.doi.org/10.1177/03635 46512436944
www.elsevier.com/locate/ymse
Demographic trends in arthroscopic and open biceps tenodesis across the United States Evan E. Vellios, MDa, Alireza K. Nazemi, MSb, Michael G. Yeranosian, MDa, Jeremiah R. Cohen, BSa, Jeffrey C. Wang, MDc, David R. McAllister, MDa, Frank A. Petrigliano, MDa,* a
Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA Department of Bioengineering, UCLA, Los Angeles, CA, USA c Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA, USA b
Background: The purpose of this study was to evaluate trends in procedures and to report on demographic data of patients undergoing arthroscopic vs. open biceps tenodesis. Methods: A retrospective review of a commercially available database (PearlDiver) was conducted to identify cases of arthroscopic and open biceps tenodesis performed between 2007 and 2011 with concurrent diagnoses of commonly associated shoulder disorders. Each record provided the patient’s age, gender, and region within the United States, and statistical significance was determined with respect to each of these demographics. Results: There were 9011 patients who underwent arthroscopic biceps tenodesis and 11,678 patients who underwent open biceps tenodesis between 2007 and 2011. The number of biceps tenodesis cases increased from 2007 to 2011 (2047 to 5832; P ¼ .015). Both arthroscopic and open biceps tenodesis procedures were performed most commonly in the 30- to 59-year-old age group (76.3% and 76.1%; P < .00001). Men underwent arthroscopic or open biceps tenodesis more commonly than women did (66.1% and 71.9%; P < .00001). Rates of both open and arthroscopic biceps tenodesis varied significantly among the Midwest, South, Northeast, and West regions (P ¼ .009; P ¼ .007); 49.8% of arthroscopic and 44.6% of open biceps tenodesis cases were associated with rotator cuff tears, whereas 14.4% of arthroscopic and 16.2% of open cases were associated with biceps tendon disorders. Conclusion: Both arthroscopic and open biceps tenodesis cases increased annually from 2007 to 2011. The majority of biceps tenodesis cases were performed in men aged 30 to 59 years, and the South had the highest overall number of cases. Further studies are required to evaluate the efficacy of these procedures with and without concomitant pathologic processes. Level of evidence: Epidemiology Study, Large Database Analysis. Ó 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. Keywords: Arthroscopic; open; biceps tenodesis; demographics; retrospective
Institutional Review Board approval was not required for this study. *Reprint requests: Frank A. Petrigliano, MD, Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, #33-55 PVUB, 10945 Le Conte Ave, Los Angeles, CA 90095, USA. E-mail address: [email protected] (F.A. Petrigliano).
Anterior shoulder pain and loss of forward flexion are common symptoms of lesions related to the long head of the biceps brachii (LHB).13 The anatomy of this region causes it to often be affected by disease of the rotator cuff
1058-2746/$ - see front matter Ó 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2015.04.021
e280 (RTC) and subacromial space.1,2,12,13,21,25 Previous studies have shown that close to 90% of patients with biceps tendinitis suffer from concomitant RTC or superior labral anterior-posterior (SLAP) tears, especially in the dominant upper extremity.5,11,17 The two most common surgical treatments for lesions of the LHB are tenotomy and tenodesis, with some studies suggesting that tenodesis provides a lower incidence of weakness, biceps discomfort, and cosmetic deformity.1,11,24,27 Tenodesis is performed most commonly to treat a partial-thickness tear of >50% diameter or a medial subluxation of the tendon in association with an RTC tear.14,21,25 Whereas tenodesis has historically been performed through an open approach, arthroscopic methods have become more popular as novel instrumentation has facilitated the ease of this procedure.26 The purpose of this study was to evaluate the trends in procedures, to report on the demographic and regional data of patients undergoing arthroscopic vs. open biceps tenodesis, and to describe the concomitant shoulder disorders commonly associated with the contemporary utilization of biceps tenodesis.
E.E. Vellios et al. Table I Age breakdown of arthroscopic and open tenodesis cases, 2007-2011 Age group (years)
Arthroscopic cases
Open cases
0-29 30-59 >60 Total
195 6876 1940 9011
329 8884 2465 11,678
(2.2%) (76.3%) (21.5%) (100%)
(2.8%) (76.1%) (21.1%) (100%)
Poisson regression analysis: P < .00001. The difference in the performance of arthroscopic and open biceps tenodesis was statistically significant for each of the 3 age groups.
Bonferroni adjustment was used to determine the significance of differences in the performance of arthroscopic and open biceps tenodesis in relation to the primary diagnosis coded. Eight of the 20 primary diagnosis codes used in this study were incorporated into this analysis (Appendix). Significance level was set at P < .05.
Results Materials and methods A retrospective review of the PearlDiver patient records database (www.pearldiverinc.com; PearlDiver, Inc., Fort Wayne, IN, USA) was performed. This is a commercially available database searchable by both Current Procedural Terminology (CPT) and International Classification of Diseases, Ninth Revision (ICD-9) codes. It contains records for approximately 20 million patients with orthopedic diagnoses obtained from an insurance company, United Healthcare (Decatur, IL, USA). The database was queried for all cases of arthroscopic biceps tenodesis (CPT-29828) and open biceps tenodesis (CPT-23430, CPT-23440) that were performed between 2007 and 2011 with concurrent diagnoses of commonly associated shoulder disorders (Appendix). The codes were searched to exclude the same code’s being counted more than once for the same patient (see Appendix for complete CPT and ICD-9 code descriptions). Each record provided the patient’s age, gender, and region within the United States. In reporting results, percentages of arthroscopic or open tenodesis were calculated from the total number of cases performed during the specified time interval and categorized according to year, gender, age group, and region.33 Furthermore, the percentage of individuals undergoing arthroscopic or open biceps tenodesis with their associated primary diagnosis was determined and again stratified according to year, gender, age group, and region.
Statistical analysis For statistical analysis, patients were categorized into 3 age groups: 0 to 29 years, 30 to 59 years, and >60 years. c2 analysis was used to assess the statistical significance of variations between regions. Poisson regression analysis was used to determine statistical significance of variations between age groups and genders. Linear regression was used to determine the significance of differences in the data from year to year. Binomial analysis with
Arthroscopic tenodesis A total of 9011 patients underwent arthroscopic biceps tenodesis between 2007 and 2011. Arthroscopic tenodesis was most common in the 30- to 59-year-old age group (Table I). Approximately two thirds of the total patients undergoing arthroscopic tenodesis between 2008 and 2011 were men and one third were women (P < .00001; Table II). Of the cases of arthroscopic tenodesis, 23.7% were performed in the Midwest region, 9.8% in the Northeast region, 50.2% in the South region, and 16.3% in the West region (Fig. 1). The differences in these percentages were statistically significant compared with one another (P ¼ .009). From 2007 to 2011, the percentage of total cases of biceps tenodesis performed arthroscopically increased from 0.15% to 48.5% (P < .00001; Table III). Furthermore, the overall number of cases of arthroscopic biceps tenodesis increased annually from 3 in 2007 to 2831 in 2011 (Table III and Fig. 2).
Open tenodesis A total of 11,678 patients underwent open biceps tenodesis between 2007 and 2011. The age stratification for patients undergoing open tenodesis was as follows: 2.8% in the 0- to 29-year age group, 76.1% in the 30- to 59-year age group, and 21.1% in the >60-year age group (Table I). Of the total patients undergoing open tenodesis, 71.9% were male and 28.1% were female (P < .0001; Table IV). Of the cases of open tenodesis, 25.5% were performed in the Midwest region, 9.2% in the Northeast region, 43.5% in the South region, and 21.8% in the West region (Table V). These
Demographic trends in biceps tenodesis procedures Table II
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Arthroscopic tenodesis gender breakdown
Gender 2007
2008
2009
2010
2011
Total
Male 66.6% (2/3) 66.7% (1115/1670) 66.6% (1416/2125) 66.2% (1578/2382) 65.4% (1852/2831) 66.1% (5963/9011) Female 33.3% (1/3) 1 33.3% (555/1678) 33.4% (709/2137) 33.8% (804/2394) 34.6% (979/2846) 33.9% (3048/9011) 100% (3/3) 100% (1670/1670) 100% (2125/2125) 100% (2382/2382) 100% (2831/2831) 100% (9011/9011) Poisson regression analysis: P < .00001. This table shows that for every year included in the analysis, except 2007, men and women received a significantly different number of arthroscopic tenodesis procedures.
Figure 1 Arthroscopic tenodesis geographic trends. A statistically significant difference was noted in comparing the total number of arthroscopic cases in each region with one another (P ¼ .009).
percentages were statistically significant compared with one another (P ¼ .0070). From 2007 to 2011, the percentage of cases of biceps tenodesis performed through an open approach decreased from 99.85% to 56.5% (P < .00001; Table III). However, the total number of cases of open biceps tenodesis increased annually from 2044 in 2007 to 3001 in 2011, with no statistically significant difference between years noted (P ¼ .106). Moreover, the total number of cases of biceps tenodesis has increased from 2047 in 2007 to 5832 in 2011 (P ¼ .015). An analysis comparing open with arthroscopic biceps tenodesis showed that for the years 2007, 2008, and 2011, there was a statistically significant difference in the number of people undergoing each procedure (P < .00001; Table III). Furthermore, comparing the total number of procedures for open and arthroscopic tenodesis by age group also showed a statistically significant difference (P < .00001; Table I).
Arthroscopic vs. open tenodesis and concomitant shoulder disorders Of the 20 ICD-9 codes cross-referenced in this study, the most common diagnoses associated with both open and arthroscopic tenodesis were 719.41 (pain in joint, shoulder), 840.4 (RTC sprain), 726.10 (RTC syndrome unspecified), 727.61 (RTC rupture), 840.6 (supraspinatus sprain), and 726.2 (other affections of shoulder region, not elsewhere classified) (Table VI). Certain cases were
associated with disorders of the biceps tendon. These included 14.4% of arthroscopic and 16.2% of open biceps tenodesis cases associated with biceps tenosynovitis (762.12) and 5.6% of arthroscopic and 9.3% of open tenodesis cases associated with biceps tendon rupture (727.62). Furthermore, 49.8% of arthroscopic and 44.6% of open tenodesis cases were associated with unspecified RTC disease (726.10), whereas 8.3% of arthroscopic and 6.6% of open tenodesis cases were associated with adhesive capsulitis (726.0). Finally, 4.4% of arthroscopic and 3.8% of open tenodesis cases were associated with calcific tendinitis (726.11), and 16.1% of arthroscopic and 14.5% of open tenodesis cases were associated with superior glenoid labrum lesions (840.7). All ICD-9 codes used in this study overlapped with CPT codes used for arthroscopic and open biceps tenodesis (Appendix).
Discussion The purpose of this study was to report on current trends in the utilization of arthroscopic and open biceps tenodesis; to demonstrate the association of these 2 procedures with concomitant shoulder disorders; and to comment on demographic data, such as age, region, and gender, of the corresponding patients. The data demonstrated an increase in the utilization of arthroscopic tenodesis from 2007 to 2011 compared with a smaller yearly increase in the overall performance of open biceps tenodesis during this same interval (P < .00001). Moreover, cases of arthroscopic and open biceps tenodesis combined have increased from 2047 in 2007 to 5832 in 2011 (P ¼ .015; Fig. 2). The increased utilization of both arthroscopic and open biceps tenodesis in our study may reflect a heightened awareness of biceps tendon disease, preference of the patient and surgeon to avoid the potential morbidity of tenotomy, and improved surgical instrumentation available for arthroscopic tenodesis. Previous studies have favored an arthroscopic suprapectoral approach because of its smaller surgical dissection, ease of revision, and shorter operative times, whereas others have advocated an open subpectoral approach because of its distal tenodesis site and ability to easily re-establish the length-tension relationship of the LHB with infrequent postoperative intertubercular sulcus pain.10,15,23 Furthermore, considerable controversy remains
48.5% (2831/5832) 51.5% (3001/5832) 100% (5832/5832) Poisson regression analysis: P < .00001 (for 2007, 2008, and 2011).
2011 2010
49.8% (2380/4773) 50.2% (2393/4773) 100% (4773/4773) 49.4% (2128/4289) 50.6% (2161/4289) 100% (4289/4289)
2009 2008
44.5% (1669/3748) 55.5% (2079/3748) 100% (3748/3748) 0.15% (3/2047) 99.85% (2044/2047) 100% (2047/2047)
2007
Percentage of arthroscopic vs. open tenodesis cases per year Table III
Arthroscopic cases per year Open cases per year
2007-2011
E.E. Vellios et al. 43.5% (9011/20,689) 56.5% (11,678/20,689) 100% (20,689/20,689)
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regarding the optimal tenodesis fixation method; some authors advocate soft tissue fixation to structures of the rotator interval, whereas others advocate bone fixation with suture anchors or interference screws.4,7,10,15,22,23,26 Further studies are needed to determine whether this observed increase in the performance of biceps tenodesis reflects an evolution in the surgical management of chronic shoulder pain and LHB disease. Regardless, it seems that biceps tenodesis is becoming an ever-increasing treatment modality for disorders of the RTC and biceps tendon. Our data demonstrate a strong association between the performance of biceps tenodesis and injuries to structures other than the biceps tendon. In fact, in cases of both arthroscopic and open tenodesis, RTC disorders were by far the most commonly recorded primary diagnoses. This is supported by multiple studies demonstrating both macroscopic and microscopic LHB tendinopathy in the setting of chronic RTC tears.3,32 In fact, a study by Walch et al consisting of 307 patients with nonoperable full-thickness RTC tears demonstrated that biceps tenotomy alone resulted in considerable improvement in 87% of patients with an average follow-up of 57 months.29 Although Walch’s study involved biceps tenotomy, it is plausible that a similar response could be seen in cases of biceps tenodesis. Numerous studies have shown that many shoulder diagnoses coexist with biceps tendonitis. In fact, Walker-Bone et al in a 2-stage cross-sectional study of upper extremity musculoskeletal injuries in the United Kingdom showed that in 28 shoulders with diagnosed biceps tendinitis, 16 fulfilled criteria for RTC tendinitis and 23 for adhesive capsulitis as well.30 As individuals age, they continue to acquire degenerative changes over time, leading to distortion of the normal shoulder anatomy, as demonstrated by Clement et al in a 2012 review stating that up to 54% of people older than 65 years have partial or complete tears of the RTC seen on magnetic resonance imaging.9 Although no comparable studies have been performed looking specifically at LHB disease, it is likely that an analogous trend exists. More important, our study demonstrates a statistically significant difference in the performance of arthroscopic vs. open tenodesis in 1-on-1 comparisons of different primary diagnoses (Table VII). For example, primary diagnoses involving structures of the RTC and superior glenoid labrum were more likely to be repaired arthroscopically, whereas primary diagnoses involving the biceps tendon were more likely to be repaired by an open approach. This may be due to the fact that arthroscopic RTC repair is the current ‘‘gold standard,’’ and some surgeons may also opt to repair the biceps tendon or SLAP tear if they have already committed to performing the RTC repair in this manner vs. performing a separate open procedure.3 Currently, no consensus for treatment of SLAP lesions or isolated biceps tendon disorders specifically has been reached, and treatments vary between arthroscopic repair, tendon tenotomy, biceps tenodesis, and debridement.6,7,31,33 In a number of recent studies, the
Demographic trends in biceps tenodesis procedures
Figure 2 Annual trend for arthroscopic, open, and total cases of biceps tenodesis. Poisson regression analysis: P < .00001.
addition of biceps tenodesis in the setting of RTC repair had equivocal effect on the subjective outcomes when performed and in comparison to tenotomy.18,20 Therefore, the forces driving the increased utilization of tenodesis are uncertain. Furthermore, the increased use of arthroscopic tenodesis in the absence of data suggesting it is more effective, faster, or less expensive should be noted. This is clearly an area for further research. Both arthroscopic and open biceps tenodesis procedures were performed most commonly in the 30- to 59-year-old age group, representing 76.3% and 76.1% of the total cases, respectively. This likely reflects the notion that tenodesis is the preferred surgical treatment for refractory biceps tendinitis in young, manually active patients because it maintains the natural length-tension relationship of the biceps muscle, allows greater elbow flexion and forearm supination strength postoperatively, and does not result in cosmetic deformity.1,11,24 The percentages of cases across the different age groups were equivalent between arthroscopic and open tenodesis. Individuals in the >60-year-old group had the second highest percentages of both arthroscopic and open tenodesis cases, but the majority of those cases occurred in those younger than 70 years. This is most likely because biceps tenotomy is recommended for older patients with sedentary lifestyles, low demands for future physical activity, and lack of concern for cosmetic appearance.11,12,21,25 Furthermore, tenotomy has the apparent advantages of being simple and quick, with less associated immobilization and rehabilitation time than for tenodesis.12 Given that the majority of patients undergoing arthroscopic and open tenodesis are older than 30 years, it is likely that the number of surgical cases will continue to increase as the population continues to age. Unfortunately, a comparative analysis for biceps tenotomy is not possible as no CPT code exists for arthroscopic tenotomy. Even if biceps tenotomy data were available, it would not change the fact that the overall performance of biceps tenodesis increased from 2007 to 2011; however, having those data would allow us to make
e283 additional meaningful statements with regard to surgical practice and surgeon preference in different regions of the United States. Interestingly, there was a significant difference in gender distribution among individuals undergoing both arthroscopic and open tenodesis, with a male to female ratio of roughly 2:1. This male predominance possibly reflects differences in physical demands placed on individuals by their respective occupations. van Rijn et al showed in their systematic review that shoulder pain was positively associated with employment that required forceful exertion and high degrees of repetition, such as that seen in industrial workers, ship welders, and butchers.28 This correlation between predominantly male occupations and shoulder injuries might help account for the considerable difference in the performance of tenodesis between men and women. Furthermore, it can be postulated that this gender discrepancy would not be seen in individuals undergoing tenotomy. Multiple studies have shown that women are less likely to suffer from a Popeye deformity than are men, making tenotomy a more appealing surgical option for women with biceps disease or chronic shoulder pain.8,16 In fact, a study by Lim et al to demonstrate patient-related risk factors for complications after tenotomy showed that of 216 patients undergoing tenotomy, 138 (64%) were female.20 Future demographic studies taking into consideration occupation and lifestyle are needed to further elucidate the cause of this discrepancy. The differences in the performance of both arthroscopic and open biceps tenodesis across the 4 regions in our study were statistically significant, with the highest percentage of both procedures occurring in the South. Possible explanations for this finding include differences in surgeon preference (i.e., surgeons in the South region may prefer biceps tenodesis over tenotomy) or patient preference (due to concerns about cosmetic appearance or possible exertional limitations), but these conclusions are difficult to make without data on biceps tenotomy. It is more likely that some of the regional differences found in our study can be attributed to pre-existing differences in the baseline patient population from which our data were drawn as 9,799,730 or 48% of the 20,484,172 patients in the PearlDiver database reside in the South. This selection bias is likely due to the distribution of patients carrying the United Healthcare group insurance plan from which the database is derived, thus making it not a true cross section of the U.S. population. Furthermore, in comparing the performance of arthroscopic and open biceps tenodesis, regional differences were minimal across all 4 regions (23.7% arthroscopic vs. 25.5% open in the Midwest, 9.2% arthroscopic vs. 9.8% open in the Northeast, 43.5% arthroscopic vs. 50.2% open in the South, and 16.3% arthroscopic vs. 21.8% open in the West). A major limitation of our study was the limited number of cases of arthroscopic biceps tenodesis coded for in 2007.
e284 It is unlikely that only 3 cases of arthroscopic biceps tenodesis were performed during this period, given that the following year showed a dramatic increase by >1500 cases. It is possible that this is partly due to an error in coding, in which arthroscopic biceps tenodesis was categorized under an incorrect CPT code by the primary surgeon, given that a CPT code for arthroscopic biceps tenodesis did not exist until late 2007. In addition, our study population was drawn from a database containing only individuals insured through a private health insurance company, United Healthcare, therefore excluding those patients who are uninsured or insured through Medicare or another private health insurance provider. As a result, it is possible that our study underestimates the overall number of both arthroscopic and open biceps tenodesis cases, especially given that the second highest performance for both procedures occurred in the >60-year age group. Moreover, we were unable (1) to determine if the operative procedures were performed on the dominant vs. nondominant arm, (2) to distinguish between the types of tenodesis techniques and fixations, (3) to determine whether a shoulder specialist or a general orthopedic surgeon performed each operation, or (4) to compare clinical outcomes based on different surgical techniques. Unfortunately, an inherent limitation of database studies such as this is the inability to examine clinical outcomes as only demographic data (including age, gender, and region), CPT codes, and ICD-9 codes are recorded, and there is no way of identifying or contacting individual patients in the database. Taking these factors into consideration is a major goal of further research in this area. Even with these limitations, we believe that this study portrays valuable data with regard to the demographic trends in the performance of biceps tenodesis in the United States.
Conclusion Our analysis indicates that the utilization of both arthroscopic and open biceps tenodesis in the United States is increasing on a yearly basis. Overall, open tenodesis appears to be a more common procedure than arthroscopic tenodesis, but arthroscopic tenodesis has shown a significantly larger increase in performance from 2007 to 2011 despite any contemporary evidence of its superiority. The performance of both arthroscopic and open biceps tenodesis appears to be highest in people aged 30 to 59 years, with both procedures being >2 times more common in men than in women. The performance of arthroscopic and open biceps tenodesis showed relatively equal distributions across the Midwest, Northeast, South, and West regions, with the South having the highest number of tenodesis cases overall. Both arthroscopic and open biceps tenodesis were performed more commonly in association with
E.E. Vellios et al. disease of the RTC than the biceps tendon despite recent literature to suggest it may or may not improve outcomes in this population.18,19 Future studies are needed to compare the clinical efficacy of open vs. arthroscopic tenodesis and their effectiveness in comparison to simple tenotomy.
Acknowledgment The authors thank members of the UCLA Statistical Consulting Group for their generous help.
Disclaimer The authors, their immediate families, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
Supplementary data Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.jse.2015.04.021.
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