Archives of Orthopaedic and Trauma Surgery

, Volume 136, Issue 5, pp 657–663 | Cite as

Chronic rupture of the long head of the biceps tendon: comparison of 2-year results following primary versus revision open subpectoral biceps tenodesis

  • Simon A. Euler
  • Marilee P. Horan
  • Michael B. Ellman
  • Joshua A. Greenspoon
  • Peter J. Millett
Arthroscopy and Sports Medicine

Abstract

Introduction

The purpose of this study was to evaluate the clinical results of surgical repair for proximal long head of the biceps (LHB) tendon ruptures comparing chronic primary and postsurgical revision LHB tendon ruptures.

Materials and methods

Patients who underwent subpectoral LHB tenodesis for chronic ruptures with a minimum of 2 years from surgery were identified. ASES and SF-12 PCS scores and surgical and demographic data were collected prospectively. At final follow-up, patients were interviewed regarding symptoms related to their biceps. Symptoms were converted into a Subjective Proximal Biceps Score (SPBS).

Results

Twenty-seven patients (22 males, 5 females) with a mean age of 61 years (range 40–76 years) underwent LHB tenodeses. Twenty patients (74.1 %) were primary repairs for chronic ruptures and seven patients (25.9 %) were revision repairs after failed prior LHB tenodesis. Twenty-five patients (92.6 %; n = 18 primary; n = 7 revision) were available for follow-up a mean of 3.8 years (range 2–6.1). The overall median postoperative SPBS showed significant improvement over the preoperative baseline (p < 0.001). Individual components of the SPBS showed substantial improvements. The SPBS significantly correlated with the postoperative ASES score (r = −0.478; p = 0.038). There were no differences in postoperative SPBSs between the primary and revision tenodesis groups. The mean postoperative ASES score was 90.3 and SF-12 PCS was 52.6.

Conclusions

Open subpectoral LHB tenodesis was a safe and effective method for the treatment of chronic LHB tendon ruptures and for the revision of failed post-surgical LHB ruptures. Patients had less pain, cramping, and deformity after LHB tenodesis. The SPBS, ASES, and SF-12 PCS scores significantly improved among this group of patients.

Level of evidence

Level III; Retrospective comparative study.

Keywords

Chronic biceps rupture Biceps score Subpectoral tenodesis Interference screw Suture anchors Revision 

Introduction

Spontaneous rupture of the long head of the biceps (LHB) tendon represents up to 90 % of all biceps tendon ruptures and is frequently associated with pathology of the rotator cuff [1, 2, 3]. Most proximal LHB tendon ruptures occur in patients over the age of 50 years and typically involve intrinsic tendon degeneration within the bicipital groove or along the biceps-labral complex [4, 5, 6, 7]. Furthermore, “iatrogenic” rupture of the LHB occurs following surgical tenotomy. Non-operative treatment is usually successful in these cases; however, LHB tenodesis may become necessary in selected patients with persistent symptoms such as pain, cramping, weakness and cosmetic deformity of the biceps muscle. Although infrequent, post-surgical rupture of a prior LHB tenodesis can lead to recurrent symptoms that may require revision tenodesis.

The clinical results following LHB tenodesis in patients with chronic symptomatology related to a previous LHB tendon rupture in either the primary or revision setting have been sparsely reported [8, 9]. Therefore, the purpose of this study was to assess the clinical results of open subpectoral LHB tenodesis in patients with chronic LHB tendon ruptures and to compare the results between primary and revision cases using an internally-derived disease-specific “Subjective Proximal Biceps Score” (SPBS). We hypothesized that patients who underwent primary tenodeses would demonstrate greater symptomatic improvement when compared to those who underwent revision tenodeses.

Methods

Institutional review board approval was obtained prior to initiation of this study.

Patient selection

Patients who underwent surgical treatment for symptomatic chronic rupture of the LHB tendon were identified from a prospective data registry. In this study, the term “chronic” was defined as spontaneous LHB tendon ruptures that occurred >6 weeks prior to initial presentation. The term “symptomatic” was defined as persistent and intolerable pain, weakness, deformity or cramping in the biceps region. Patients were included if they were (1) >18 years of age at the time of surgery, (2) were at least 2 years out of the index surgery (revision group, open subpectoral biceps tenodesis using interference screws) and (3) underwent primary (primary group) or revision (revision group) open subpectoral biceps tenodeses using either interference screws or suture anchors. Patients who underwent LHB tenodesis for chronic or revision LHB rupture with concomitant rotator cuff repair were also included. In those patients, tenodesis of the LHB was indicated due to either the desire for a removal of deformity, the specific weakness or the localized pain in the biceps area, based on the SPBS.

Surgical techniques

All patients underwent initial diagnostic arthroscopy in the modified beach-chair position to address any intra-articular pathology. After the administration of a regional interscalene block and the induction of general anesthesia, the operative extremity was draped free under sterile conditions with the arm secured in a pneumatic arm holder. A standard posterior portal was established and, under direct visualization, an anterosuperior portal was also created. Diagnostic arthroscopy was then performed to identify and address any coexistent intra-articular pathology. The proximal stump of the LHB tendon was removed from the joint when present. When access to the subacromial space was required, an accessory lateral portal was established to address concomitant subacromial and/or rotator cuff pathologies. When necessary, rotator cuff repair was performed at this time.

Following the conclusion of diagnostic arthroscopy, open subpectoral biceps tenodesis was performed [10]. With the arm abducted and slightly internally rotated, the inferior margin of the pectoralis major tendon was palpated. An incision was made extending from 1 cm superior to 3 cm inferior to the inferior border of the pectoralis major tendon. The short head of the biceps and the pectoralis major tendons were identified and the LHB tendon was typically retrieved within this interval. The ruptured LHB tendon was detached from the wound and its quality was assessed. In chronic cases, there was often a pseudotendon present in the inferior aspect of the bicipital groove. When the LHB tendon was absent proximally at the level of the pectoralis major, dissection was carried distally until the proximal end of the ruptured LHB tendon was discovered. In all instances the tendon could be found. When a pseudotendon was present, the proximal end of the LHB tendon was excised in order to restore the appropriate length-tension relationship of the biceps muscle by visualizing the popeye deformity and when it was eliminated. The remaining proximal 15–20 mm of the LHB tendon was then whip-stitched using No. 2 non-absorbable high-strength suture (FiberWire, Arthrex, Naples, FL). When the LHB stump was short or of poor quality, no. 2 sutures were passed into the myotendinous junction.

Tenodeses with interference screws

LHB tenodeses using interference screws were performed when tendon quality was adequate, similar to the technique described by Mazzocca et al (Video 1) [11]. Briefly, subperiosteal dissection was performed approximately 1 cm proximal to the inferior border of the pectoralis major tendon corresponding to the inferior one-third of the bicipital groove. A 7- or 8-mm reamer was used to create a unicortical bone tunnel to a depth of approximately 15 mm. One suture limb from the whip-stitched tendon was threaded through a specially-designed driver and an appropriately sized PEEK tenodesis screw (Arthrex, Inc; Naples, FL). The screw which was the same diameter as the socket was placed into the bone and advanced until the screw was flush with the anterior cortex of the humerus. The remaining suture limb was then tied to the suture limb that passed through the screw to enhance the fixation and prevent tendon slippage (Fig. 1). When there was a lot of tension or when the tendon quality was poor, additional fixation was achieved using multiple no. 1 absorbable sutures from the LHB tendon to the inferior border of the pectoralis major laterally.
Fig. 1

Figure showing a LHB tenodeses with an interference screw

Tenodeses with suture anchors

Suture anchor tenodeses were performed in cases of tendon shortening or poor tendon quality. The periosteum along the anterior humeral shaft near the site of tenodesis was roughened to enhance healing of the biceps tendon stump and the musculotendinous junction to the humerus. Permanent No. 2 Krackow-type interlocking sutures were woven into the musculotendinous junction and the overlying myofascia of the biceps muscle. Prior to the insertion of suture anchors, muscle tension was assessed qualitatively by pulling upwards on the biceps tendon with the elbow in 90° of flexion. The goal of this maneuver was to determine an appropriate location for the tenodesis/myodesis that would restore normal resting tension and cosmesis. Typically, two appropriately-sized unicortical bone tunnels were drilled in the proposed tenodesis site and two knotless push-lock suture anchors (Arthrex, Inc; Naples, FL) were inserted and tightened, thus completing the tenodesis (Fig. 2).
Fig. 2

Figure showing a LHB tenodeses with suture anchors

Postoperative rehabilitation

Following isolated LHB tenodeses, patients were restricted from performing resisted elbow flexion maneuvers for at least 6 weeks after surgery. When the quality of the LHB tendon was poor, active elbow flexion was restricted for approximately 4 weeks. Overhead strengthening and heavy lifting were also delayed for approximately 3 months. Otherwise, full active and passive range of motion was allowed immediately postoperatively. When concomitant rotator cuff repair was performed, additional rehabilitation was implemented. Specific rehabilitation protocols following rotator cuff repair have been described elsewhere [12, 13].

Data collection

Prospective data included Short Form 12 Physical Component Summary (SF-12 PCS) and American Shoulder and Elbow Surgeon (ASES) scores, surgical data (concomitant findings and the hardware used for tenodesis) and demographic data (age, gender, surgical history, time from injury to surgery and the length of follow-up).

At final follow-up, patients were contacted during the review process to collect subjective data. All patients were asked each of the following questions regarding the status of their biceps muscle both pre- and postoperatively:
  • Do you feel pain in the area of the biceps muscle?

  • Besides the pain, is there any cramping in the biceps muscle?

  • Do you have a deformity in the biceps muscle?

  • Is the strength of your biceps muscle normal?

According to the information obtained from each patient, the SPBS was calculated and used in this cohort both pre- and postoperatively to help describe the overall symptomatology related to the biceps muscle in the setting of prior LHB rupture (Table 1). In addition, patients were contacted and asked to complete postoperative surveys containing the ASES score, SF-12 PCS score, and satisfaction.
Table 1

The “Subjective Proximal Biceps Score” (SPBS) used for the evaluation of preoperative and postoperative symptoms related to the biceps muscle

 

0

1

2

3

Pain

None

Mild

Moderate

Severe

Strength (flexion and supination)

Unrestricted

Activity related weakness (mild)

Weak with activities of daily living (moderate)

Weak with all activities (severe)

Appearance/cosmesis

Normal

Mild deformity, asymptomatic

Asymptomatic popeye or mild deformity that is bothersome

Symptomatic popeye deformity

Cramping

None

Mild

Moderate

Continuous

Interpretation: total score 0–2 = excellent; 3–4 = good; 5–8 = moderate; 9–12 = poor

Statistical analyses

Due to the small sample size and the postoperative SPBS not being normally distributed (p < 0.05, Kolmogorov–Smirnov test), the median and interquartile range (IQR) was reported. Correlation between preoperative SF-12 PCS and preoperative SPBS was determined using Pearson correlation coefficients (r). Pre- and postoperative SPBSs were compared using a repeated-measures Wilcoxon signed rank test since it compared pre- and postoperative scores in the same patient. Comparisons between two independent groups were performed using the Mann Whitney U test. Chi square analysis was used to determine differences in binary variables. Statistical analyses were performed using SPSS software package (version 18; SPSS, Chicago, IL). All reported P values are two-tailed, with an α level of 0.05 indicating statistical significance.

Results

Query of a prospective surgical registry identified 876 patients over the age of 18 years who underwent open subpectoral biceps tenodesis and were at least 2 years out of the index surgery. After review of each record, 849 patients were excluded since these LHB tenodeses were performed for indications other than symptomatic chronic LHB tendon rupture or failed prior LHB tenodesis. Therefore, 27 patients were included in this study. There were 22 males (81.5 %) and 5 females (18.5 %) with a mean age of 61 years (range 40–76 years). The median interval between the date of injury and the date of surgery was 9.0 months (range 6 weeks–7.5 years). Nine patients (33.3 %) were treated for isolated chronic LHB ruptures whereas 18 patients (66.7 %) underwent concomitant rotator cuff repair. Twenty-three patients (85.1 %) underwent LHB tenodesis with an interference screw and four patients (14.8 %) underwent LHB tenodesis with suture anchors. Twenty patients (74.1 %) underwent primary LHB tenodesis (primary group) and seven patients (25.9 %) underwent revision LHB tenodesis (revision group). Table 2 presents a comparison of demographic and surgical variables between the primary and revision groups. There were no intra- or postoperative complications.
Table 2

Summary of demographic and surgical variables

 

Primary group (n = 20)

Revision group (n = 7)

Mean age, years (range)

60 (40–71)

63 (47–75)

Male gender, n (%)

17 (85)

5 (71)

Median symptom duration, months (range)

8.7 (1.5–91.4)

12.1 (1.5–39.0)

Concomitant rotator cuff repair, n (%)

13 (65)

5 (71)

Interference screw fixation, n (%)

18 (90)

5 (71)

Of the 27 patients that were included, 25 patients (n = 18 in primary group; n = 7 in revision group) were available for follow-up regarding the SPBS at a mean of 3.8 years postoperatively (range 2.3–6.1 years). Preoperative SF-12 PCS scores were significantly correlated with total preoperative SPBSs (r = −0.499; p = 0.015) and postoperative ASES scores were significantly correlated with total postoperative SPBSs (r = −0.478; p = 0.038). Overall, the median postoperative SPBS demonstrated a significant improvement when compared to the preoperative baseline [8 (IQR 7–9) vs. 1 (IQR 0–3); p < 0.001]. Each category within the SPBS also demonstrated substantial improvements from pre- to postoperatively (Table 3; Fig. 3). Median total preoperative SPBSs for the primary group were significantly decreased when compared to the revision group [7.5 (IQR 7–9) vs. 9 (IQR 9–10); p = 0.015]. Median total postoperative SPBSs for the primary group were not significantly different from the revision group [0.5 (IQR 0–3) vs. 2 (IQR 0–9); p = 0.153].
Table 3

Summary of the pre- to postoperative improvement in each category of the SPBS

Group

Improvementa

Pain

Strength

Deformity

Cramping

Improved

Improved

Improved

Improved

Primary

17/18

12/18

12/17

11/13

Revision

7/7

6/7

7/7

3/4

aImprovement occurred when postoperative scores had decreased relative to non-zero preoperative scores. Non-improvement occurred when postoperative scores had remained the same or had increased relative to preoperative scores. Matching pre- and postoperative scores of “0” were not considered improvement or non-improvement

Fig. 3

Bar graphs representing pre- and postoperative SPBS component scores for the entire cohort

Twenty patients (74 %) completed the shoulder survey containing postoperative ASES and SF-12 PCS scores as well as patient satisfaction. The ASES score significantly improved from 52.0 preoperatively to 90.7 postoperatively (p = 0.006). The SF-12 PCS score also significantly improved from 39.9 to 52.5 (p < 0.001). There were no statistically significant differences between preoperative ASES or SF-12 PCS scores for patients in the primary group compared to the revision group. Similarly, there were no differences in postoperative scores between the two groups. The median reported patient satisfaction was 10/10 (range 2–10).

Discussion

In this study, surgical treatment for chronic and revision LHB tendon ruptures resulted in clinical improvements in this patient cohort. Median postoperative SPBSs demonstrated a statistically significant improvement when compared to the median preoperative baseline. Each category within the SPBS also showed substantial improvements. Although preoperative SPBSs were significantly different between the primary and revision groups, there was no significant difference in postoperative SPBSs. Open subpectoral biceps tenodesis for chronic symptomatic rupture of the LHB tendon and for a failed prior LHB tenodesis was a safe and effective treatment modality that decreased pain and improved function in this patient cohort. There were significant improvements in both the ASES and SF-12 PCS scores. The SPBS significantly correlated with the SF-12 PCS preoperatively and the ASES score postoperatively suggesting initial validity of the SPBSs.

While most proximal LHB tendon ruptures are asymptomatic, some result in pain, cramping, cosmetic deformity and weakness with supination and/or elbow flexion. Currently, there are no validated outcomes measures for the shoulder or elbow that are designed to evaluate the symptoms related to proximal LHB tendon rupture. In 2011, Scheibel et al. [14] presented a score to evaluate the long head of the biceps (LHB score). This score includes the evaluation of pain and cramps, grading of the cosmetic result, and the measurement of elbow flexion strength using an isometric dynamometer. However, to simplify the score and to make it easily conductible for every surgeon without the need for any additional testing devices, we derived a subjective score version. We therefore devised the SPBS as a method to specifically address and evaluate the subjective functional limitations both before and after LHB tenodesis in a series of patients with chronic rupture of the LHB tendon. In this study, the median overall preoperative SPBS was 8 (IQR 7–9) and the median overall postoperative SPBS was 1 (IQR 1–3) (p < 0.001). Substantial improvements were also seen in each sub-category of the SPBS (pain, weakness, cosmesis and cramping) (see Fig. 3). There were no differences in the SPBS between the primary and revision tenodesis groups, although both groups demonstrated a statistically significant improvement over their preoperative baselines. These results suggest that significant improvements can be expected following open subpectoral LHB tenodesis for chronic rupture of the LHB tendon in both primary and revision cases; however, future studies are needed to formally validate the SPBS as an outcomes measure.

To date, few studies have been published that evaluated the clinical outcomes following LHB tenodesis for chronic rupture of the LHB tendon. Anthony et al [15] included 11 symptomatic patients (mean age 43) that received open subpectoral tenodesis for isolated auto-ruptures (5 of 11) or following a tenotomy (6 of 11). In their study, tenodesis resolved cramping as well as deformity completely, and pain was reduced significantly, allowing predictable return to activity and patient satisfaction. Ng and Funk [9] reviewed a series of 11 consecutive patients (mean age, 41 years) who underwent open subpectoral biceps tenodeses for chronic LHB ruptures. Tenodeses were performed with interference screws in five patients (45.5 %) and suture anchors in six patients (54.5 %) according to tendon quality. Similar to our study, the authors contacted each patient and asked them various questions regarding the current function of their biceps muscle compared to their preoperative status. According to their results, all but one patient indicated an improvement over their preoperative statuses for each of the pain, strength and cosmesis categories. Tucker and Dutta [16] reported similar results in three patients who underwent LHB tenodeses with interference screws. In our study, 23/25 patients (92 %) showed improvements in the overall SPBS with a mean pre- to postoperative change of −6 points (range 0 to −10 points). Both patients who did not show improvement were in the revision group and their LHB tendons were tenodesed with interference screws.

This study has several limitations that should be noted. First, only a limited number of patients were eligible for inclusion since most patients with chronic LHB ruptures are successfully treated nonoperatively. The limited number of patients included in this study also draws questions regarding statistical power, especially when comparing the two groups. For this reason, we chose to summarize the results of each category of the SPBS to help prevent data misinterpretation (see Table 3). Second, because patients were personally interviewed to gather the information for the SPBS, potential for recall bias, interview bias, detection bias and problems with patient comprehension of the questions being asked exist. Third, because patients were interviewed at final follow-up regarding preoperative status, we cannot rule out the possibility of recall bias. Concerning the SPBS, we could show a significant correlation with the postoperative ASES score. However, the SPBS has not been formally validated and future studies are needed to confirm its utility. Fourth, only 74 % of patients were willing to complete the postoperative surveys leading to the possibility of selection bias. Lastly, it is not possible to determine how much the repair of the chronic biceps rupture contributed to improvements in the ASES and SF-12 PCS scores as concomitant pathologies including pathology of the rotator cuff were also addressed at the time of surgery.

Despite these limitations, this study involved a large number of patients treated surgically for LHB ruptures. Most orthopaedic surgeons have seen patients who were dissatisfied with their outcomes after non-operative treatment of their LHB ruptures or after failure of a prior tenodeses. The results demonstrated in this study suggest that surgical treatment can be helpful to decrease pain and cramping and improve function and cosmesis, even in chronic cases and cases with short tendons.

Conclusion

Open subpectoral LHB tenodesis was a safe and effective method for the treatment of chronic LHB tendon ruptures and for the revision of failed post-surgical LHB ruptures. Patients had less pain, cramping, and deformity after LHB tenodesis. The SPBS, ASES, and SF-12 PCS scores significantly improved among this group of patients.

Notes

Compliance with ethical standards

Conflict of interest

This research was supported by the Steadman Philippon Research Institute. The Institute receives research support from the following entities: Smith and Nephew Endoscopy, Inc.; Arthrex, Inc.; Siemens Medical Solutions USA, Inc.; Ossur Americas, Inc.; Opedix, Inc. This work was not supported directly by outside funding or grants. Peter J. Millett has received from Arthrex something of value (exceeding the equivalent of US$500) not related to this manuscript or research. He is a consultant and receives payments from Arthrex and has stock options in GameReady and Vumedi. He is also a consultant for Myos. Dr. Simon Euler had his research position at the Steadman Philippon Research institute funded by Arthrex. The other authors receive support from the Steadman Philippon Research Institute.

Supplementary material

Video 1: This surgical video demonstrates a case of a revision subpectoral LHB tenodesis for symptomatic chronic LHB rupture following failed primary tenodesis using an interference screw. The rupture occurred six weeks prior to this intervention. (MP4 45261 kb)

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Copyright information

© Springer-Verlag Berlin Heidelberg 2016

Authors and Affiliations

  1. 1.Center for Outcomes-based Orthopaedic Research (COOR)Steadman Philippon Research InstituteVailUSA
  2. 2.The Steadman ClinicVailUSA
  3. 3.Department of Trauma Surgery and Sports TraumatologyMedical University InnsbruckInnsbruckAustria

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