Systematic Review of Biceps Tenodesis: Arthroscopic Versus Open Vineet Thomas Abraham, M.B.B.S., M.S., Bryan H. M. Tan, F.R.C.S.(Edin), and V. Prem Kumar, M.B.B.S., F.R.C.S.(Edin), F.R.C.S.(Glas)
Purpose: We present a systematic review of the recent literature regarding the use of arthroscopic and open methods of tenodesis for lesions of the long head of the biceps brachii and present an analysis of the subjective and objective outcomes after these 2 procedures. Methods: PubMed was carefully reviewed for suitable articles relating to biceps tenodesis, both open and arthroscopic. We included studies reporting on the clinical outcomes of these 2 procedures that were of Level I to IV evidence and were published in the English language. The primary clinical outcomes for each study were determined, normalized, and reported as the percentage of good or excellent results versus poor results based on the outcome scores and criteria laid out by the authors in each of the studies. The exclusion criteria included studies in which biceps tenodesis was performed in patients with concomitant rotator cuff repairs, nonhuman studies, and biomechanical studies. Results: A total of 16 studies met our inclusion criteria. Among all studies, a total of 205 arthroscopic tenodesis procedures and a total of 271 open tenodesis procedures were performed. Among the 271 open tenodesis patients, 98% had a good or excellent outcome, with a poor outcome in 5 patients (2%). Among the 205 patients who underwent arthroscopic tenodesis, 98% had a good or excellent outcome, with a poor outcome in 5 patients (2%). Conclusions: Both open and arthroscopic biceps tenodesis provided satisfactory outcomes in most patients, and there were no identiﬁable differences in this review. Level of Evidence: Level IV, systematic review of Level III and IV studies.
he long head of the biceps (LHB) tendon is often implicated in various shoulder pathologies because of its anatomic course and its close relation to the rotator cuff and the superior labrum of the glenoid.1 There is a persistent controversy regarding the function of the biceps tendon and the management of the various disorders associated with it.2 Nonoperative treatment continues to have a role for patients who have mild symptoms with tendinopathy or partial tears of the biceps tendon. Nonoperative treatment usually involves rest, activity modiﬁcation, use of nonsteroidal anti-inﬂammatory drugs, physical therapy, and
From the Department of Orthopaedic Surgery, National University Hospital (V.T.A., B.H.M.T.); and Department of Orthopaedic Surgery, Yong Loo Lin School of Medicine, National University of Singapore (V.P.K.), Singapore, Singapore. The authors report that they have no conﬂicts of interest in the authorship and publication of this article. Received May 19, 2015; accepted July 31, 2015. Address correspondence to Vineet Thomas Abraham, M.B.B.S., M.S., Department of Orthopaedic Surgery, National University Hospital, 1E Kent Ridge Road, Singapore 119228, Singapore. E-mail: [email protected]
Ó 2015 by the Arthroscopy Association of North America 0749-8063/15465/$36.00 http://dx.doi.org/10.1016/j.arthro.2015.07.028
corticosteroid injections. Surgical treatment is considered for patients with partial tears of the biceps tendon, biceps pulley lesions, and SLAP lesions. The choice of treatmentdwhether repair, tenotomy, or biceps tenodesisdremains controversial.3-5 Biceps tenotomy is usually indicated in patients older than 60 years and can be performed relatively simply arthroscopically. It produces pain relief but is associated with problems such as cramping pain, restricted elbow ﬂexion, cosmetic deformity (Popeye sign), fatigue pain, and a decrease in elbow ﬂexion and supination power.3,4 Biceps tenodesis is the preferred technique to manage LHB lesions especially in younger patients, laborers, athletes, and patients who want to avoid a cosmetic deformity. Tenodesis, although requiring a longer rehabilitation period and having increased technical difﬁculty in its execution, allows for a better return to physical activity with a lower incidence of cosmetic deformity.6,7 Biceps tenodesis can be performed by arthroscopy or a mini-open or open technique. Mazzocca et al.8 performed a biomechanical assessment of 4 tenodesis techniques (open subpectoral bone tunnel biceps tenodesis, arthroscopic interference screw technique, open subpectoral interference screw ﬁxation technique, and arthroscopic suture anchor tenodesis).
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V. T. ABRAHAM ET AL.
Their results showed no statistically signiﬁcant difference in the ultimate failure strength among any of the techniques used. In the past few years, there have been a few studies that have evaluated the outcomes of both arthroscopic biceps tenodesis and open tenodesis in the treatment of LHB lesions. Unfortunately, there remains no clear consensus on which surgical treatment is optimal. The purpose of this study was to conduct a systematic review of the literature on biceps tenodesis, both arthroscopic and open, and present an analysis of the subjective and objective outcomes after these 2 procedures. We hypothesized that both arthroscopic and open biceps tenodesis will have similar subjective and objective outcomes.
Methods We performed a systematic review of the results of biceps tenodesis carried out by both open and arthroscopic methods for the management of LHB lesions. The inclusion criteria consisted of outcome studies of biceps tenodesis for isolated LHB lesions or those associated with SLAP tears, using either open or arthroscopic techniques. Additional inclusion criteria comprised studies with Level IV or higher evidence published in peer-reviewed journals in the English language. We included studies published between January 2008 and April 2015. The exclusion criteria were studies in which biceps tenodesis was performed in patients with concomitant rotator cuff repairs, nonhuman studies, and biomechanical studies. The bibliographies of the articles identiﬁed, as well as those of any review articles, were examined to ensure a complete search. We independently searched PubMed for the key phrases “arthroscopic biceps tenodesis,” “open biceps tenodesis,” “biceps tenodesis,” and “long head of biceps brachii.” All articles that were identiﬁed using these search terms were then manually reviewed and discussed among the authors, and a decision whether to include or exclude them was made based on our inclusion and exclusion criteria. Data extracted from each study included level of evidence, number of patients, demographic characteristics of patients studied, tenodesis techniques, length of follow-up, clinical outcome measures including outcome scores, and complications. We analyzed each study to determine the primary outcome measurement used by the different authors. These included both subjective patient evaluations and validated objective shoulder scoring systems. When the articles included subjective patient evaluation, the breakdown presented by the authors was used to divide patients into those with good or excellent results and those with poor results. When only validated scoring systems were used by the authors in their studies, then the average primary outcome measurement (score) was used to separate
Table 1. Grading of Objective Scores Scoring System Constant score9 ASES score10 SANE score11
Good or Excellent 40 70 70