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Background Pathologies of the long head of the biceps (LHB) tendon are frequently seen as concomitant pathologies during arthroscopic surgery for rotator cuff injuries or the labroligamentous complex of the shoulder. Currently, there are two treatment options: Tenotomy is quick and easy to perform with low complications rates, but has limited functional results, especially in demanding patients; tenodesis of the tendon has shown beneficial cosmetic and functional results, but usually requires an implant for tendon-to-bone attachment and, therefore, carries the risk of implant-related complications. The implant-free loop tenodesis (LT) procedure was developed to combine the advantages of both treatment modalities and has shown promising functional and cosmetic results in a prospective pilot study. This study aims to establish the implant-free LT procedure versus arthroscopic anchor tenodesis (AAT) for the treatment of LHB pathologies during shoulder arthroscopy in terms of structural and functional outcome. Methods A national multi-center, two-arm, parallel-group, randomized, controlled, non-inferiority trial will be conducted. Patients are eligible for trial participation if they are at least 18 years of age and present to one of the five enrolling centers with LHB tendon-associated complaints and MRI-confirmed LHB tendinopathy, instability due to SLAP or pulley lesions, or partial rupture. Patients with current or previous shoulder injury that would interfere with post-treatment rehabilitation or study assessment will be excluded from study participation. Participating patients will be randomized 1:1 to receive either LT or AAT and will be followed up for 24 months after surgery. The primary endpoint will be the functional and cosmetic outcome as assessed by the biceps-specific LHB score at 12 months after surgery. Secondary outcomes include assessment of surgery-related complications, overall shoulder and arm function, and structural outcome as evaluated by ultrasound and an additional MRI scan at the final study visit. Discussion The study will evaluate whether the implant-free loop tenodesis procedure is non-inferior to arthroscopic implant-based tenodesis in terms of functional and cosmetic results at 12 months post-treatment. Trial registration Trial was prospectively registered at the German Clinical Trials Register (DRKS) on 12 th June 2024, Registration-ID DRKS00034361, https://drks.de/search/de/trial/DRKS00034361 .

Background Optimal treatment of the diseased long head of the biceps (LHB) tendon during rotator cuff repair remains a topic of debate: tenotomy or tenodesis. A recent meta analysis revealed no difference in strength or functional outcome between treatments. The included studies varied in methodological quality, and only two were randomized controlled trials (RCTs). As strong evidence in favor of either tenotomy or tenodesis is still lacking, we designed this randomized controlled trial to compare functional outcomes after tenotomy and tenodesis when performed in adjunct to arthroscopic rotator cuff repair. Methods Patients older than 50 years with a supraspinatus and/or infraspinatus tendon rupture sized smaller than 3 cm, who are encountered with LHB pathology, will be randomized to either LHB tenotomy or LHB tenodesis. Clinical and patient-reported data will be collected pre-operatively, 6 weeks, 3 months and 1 year after surgery. Primary outcome is overall shoulder function evaluated with the Constant score at 1 year after surgery. As additional measures of shoulder function, two patient reported outcomes (the Dutch Oxford Shoulder Test and the Disabilities of the Arm Shoulder and Hand questionnaire) will be assessed. Other evaluations include cosmetic appearance evaluated by the “Popeye” deformity, elbow flexion strength, arm cramping pain, MRI-based location of the biceps tendon, quality of life, and duration of surgery. To detect non-inferiority with a one-sided, two-sample t-test with 80 % power and a significance level (alpha) of 0.025, the required sample size is 98 patients. Discussion Treatment of LHB tendon lesions is performed differently around the world and meta analyses do not provide conclusive evidence in favor of one of these treatments. This study will strengthen evidence on the risks and benefits of LHB tenotomy and tenodesis in adjunct to a rotator cuff repair, which is important for managing patient expectations. Trial registration Dutch Trial Register ( NTR3255 ) January 12, 2012, ClinicalTrials.gov (ID NCT02655848 ) January 14, 2016, retrospectively registered.

    Purpose This study aimed to compare the short-term outcomes of ACL reconstruction (ACLR) alone, ACLR with lateral tenodesis, and ACL and ALL reconstruction. Methods A retrospective cohort of prospectively collected data on all ACL procedures was performed at Aspetar Specialized Orthopaedic and Sports Medicine Hospital between January 2020 and January 2021. Patients were treated with ACLR alone, ACLR with lateral tenodesis, or ACLR with ALL reconstruction. The primary outcome was the subjective International Knee Documentation Committee (sIKDC) score. The secondary outcomes were the ACL Return to Sport after Injury (ACL-RSI) scores, pivot shift grade, subjective knee stability, and subjective pain on activity. Results A total of 100 cases were included. The most common technique was ACLR with lateral tenodesis (42%), followed by ACLR alone (38%) and ACL with ALL reconstruction (20%). The mean age was 28.15 years (15–60), and 94% of the patients were males. Meniscal procedures were more frequent in the ACLR alone group (65.8%). There was no association between subjective stability, sIKDC, ACL-RSI, and pivot shift grade and the three ACLR techniques while adjusting for age, sex, and concomitant meniscus procedures at six weeks, 12 weeks, six months, and nine months. However, there was a significant decrease in postoperative flexion in the ACL and ALL reconstruction group by a mean of 22° (95% CI − 40.7 − 3.4; P  = 0.02) at 6 weeks compared to ACLR alone, which was not evident on later follow-ups. Conclusion ACLR with/without lateral augmentation procedures yields similar subjective IKDC, ACL-RSI, pivot shift grade, and subjective knee instability at short-term follow-up. Therefore, lateral extra-articular augmentation procedures are safe to be performed.

Introduction Lateral extra-articular tenodesis (LET) is a surgical technique that can be used in conjunction with anterior cruciate ligament reconstruction (ACLR), improving rotational stability and reducing the risk of anterior cruciate ligament (ACL) re-rupture. However, as with any surgical procedure, LET carries a risk of complications. Despite numerous articles published in recent decades discussing LET in the context of ACLR, relatively few complications associated with the LET procedure have been documented in the literature. This study aimed to systematically review adverse events associted with the LET procedure when combined with ACLR. Material and methods The following key terms were used: (extra-articular OR extraarticular) AND (tenodesis OR plasty OR augmentation OR procedure or reconstruction OR reconstructive OR surgical OR surgery OR technique) AND (ACL OR anterior cruciate ligament), with no limits regarding the year of publication in PubMed, ScienceDirect, Cochrane Central, Web of Science, and Embase databases. English-language clinical human studies with evidence levels I-IV were included. Results This analysis evaluated seven articles published between 1999 and 2023. Level IV evidence was identified in the majority of studies ( n  = 5), level III evidence was found in one ( n  = 1), and level I evidence was noted in another ( n  = 1). Nine distinct types of complications were identified with rates rangingfrom 0.6% to 17% across the analysed studies. The modified Lemaire technique had the highest complication rate, reaching 7.5%. Overall, the complication rate across all reviewed LET techniques in this study was 4.2%. Conclusion This is the first study to systematically document the occurrence of complications in LET. The most common problems included LET hardware irritation – predominantly after staple fixation, and subsequent removal, haematoma over the LET site, and pain over the LET site. The analysed studies show that combining LET with ACLR appears to be a safe procedure associated with infrequent and mild side effects.

IntroductionCurrently there exists no clear evidence concerning the surgical treatment of LHB lesions with either tenotomy or tenodesis. The aim of the study is therefore to evaluate elbow flexion and forearm supination force as well as the biceps muscle distalization according to both techniques in isolated LHB lesions.MethodsConsecutive patients aged 40–70 years with shoulder arthroscopies for isolated SLAP or biceps pulley lesions were prospectively randomized to arthroscopic suprapectoral intraosseous LHB tenodesis or tenotomy. Pre-, 6 and 12 months postoperatively, the SST, ASES, Constant–Murley and LHB scores were recorded. The elbow flexion force was measured in 10°/90° flexion, the supination force in neutral/pronation position. In addition, the maximum upper-arm circumference and its position relative to the radial epicondyle of the humerus were evaluated preoperatively and in follow-up.Results20/22 patients (mean age 52.0 ± 8.5; range 36–63 years, 11 male) completed the follow-up. 9/20 were treated with LHB tenodesis (mean age 51.5 ± 9.5; range 37–63 years, 7 male) and 11/20 with tenotomy (mean age 52.8 ± 8.0; range 36–62 years, 4 male). The force measurements and scores showed no significant difference after 12 months. Tenodesis achieved a significant increase in force 6 months postoperatively compared to preoperatively. One tenodesis patient and three tenotomy patients showed a postoperative popeye-sign deformity.ConclusionThis prospective randomized study comparing LHB tenodesis and tenotomy in isolated LHB lesions has shown no significant difference in elbow flexion and forearm supination force and clinical scores after 12 months. After LHB tenotomy, there was a non-significant trend for a higher rate of popeye-sign deformities of the upper arm and biceps muscle cramps.

Purpose There is limited clinical outcome data comparing fixation methods for tenodesis of the long head of the biceps tendon (LHBT), particularly button fixation. The purpose of this study was to compare clinical outcomes, patient-reported outcomes, and return to sport (RTS) between patients undergoing LHBT with bicortical versus unicortical button technique. The authors hypothesized these fixation methods would be similar for all outcomes. Methods Patients who underwent LHBT using unicortical or bicortical button fixation with minimum 2-year follow-up were identified. Postoperative outcomes were evaluated using the American Shoulder and Elbow Surgeons (ASES) questionnaire and visual analogue scale (VAS) pain score. A sports activity survey was collected to assess baseline sport participation and ability to return to pre-injury activities. Continuous variables were analyzed using the Mann–Whitney-U test. Categorical variables were analyzed using Chi-squared tests. Multivariable logistic and linear regression were performed to determine predictors of RTS and time to RTS. Results Sixty-four subjects (19 unicortical and 45 bicortical button fixation) were included (average follow-up 3.5 (range: 2.0–7.8) years). There were no significant differences found between button groups for VAS pain score (1.5 vs. 1.2; p  = 0.876), VAS pain during sport score (1.6 vs. 1.1, p  = 0.398), and ASES score (66 vs. 71; p  = 0.294). There were no significant differences in rate of RTS (75.0 vs. 77.4%; p  = 0.885) or average time to return to sport (11.7 ± 7.3 vs. 7.0 ± 4.0 months; p  = 0.081) between groups. Conclusion There were no significant differences in clinical outcomes, pain, or return to sport between patients who underwent LHBT with unicortical or bicortical button fixation.

Purpose The present study aimed to propose a modified intra-articular transtendinous looped biceps tenodesis (mTLBT) using a suture anchor and to compare the functional outcomes and incidence of Popeye deformities between biceps tenotomy and mTLBT. Methods Medical records of patients who underwent either tenotomy or mTLBT for the long head of the biceps tendon (LHBT) lesion between January 2016 and April 2021 were retrospectively reviewed. The inclusion criteria were patients aged 40–70 years with LHBT pathologies, such as superior labrum anterior to posterior (SLAP) lesions > type II, LHBT pulley system rupture with bicipital instability, and intra-articular LHBT tear. The exclusion criteria were full-thickness supraspinatus tears, frozen shoulder, shoulder fracture, and postoperative traumatic events that affected the operated shoulder. All patients were followed up for at least 1 year. Popeye deformity, bicipital cramping pain, visual analog scale (VAS) pain score, and functional outcome scores (University of California at Los Angeles [UCLA] and American Shoulder and Elbow Surgeons [ASES] scores) were recorded. Fisher’s exact test and Chi-square test were used for categorical variables, whereas the Mann–Whitney U test was used for nonparametric variables. Results The mTLBT and tenotomy groups included 15 and 40 patients, respectively. The incidence of Popeye deformity and biceps cramping pain in the tenotomy group (52.5% and 50%, respectively) was significantly higher than that in the mTLBT group (13.3% and 20%, respectively) ( p  = 0.009 and p  = 0.045, respectively). The postoperative VAS, UCLA, and ASES scores were not significantly different between the two groups. One patient in the tenodesis group experienced metallic-anchor pullout. Conclusion mTLBT is an arthroscopic intra-articular top of the groove tenodesis that can be performed completely in the intra-articular space and is especially suitable for patients with an intact or partially torn rotator cuff. This technique is reliable for treating biceps pathologies as it results in similar functional outcome scores, lesser biceps cramping pain, and less frequent Popeye deformity compared to biceps tenotomy. Level of Evidence III.

Background The best location for biceps tenodesis is controversial as surgeons have begun to question whether tenodesis location affects the incidence of residual bicipital postoperative pain. An open distal tenodesis technique has been previously proposed to eliminate remaining symptoms at the bicipital groove. Questions/purposes We asked the following questions: (1) Does a higher tenodesis in the biceps groove result in postoperative pain? And (2) can the tenodesis location be successfully moved more distally (“suprapectoral tenodesis”) by an arthroscopic technique? Methods We retrospectively reviewed 17 patients undergoing arthroscopic biceps tenodesis and evaluated their tenodesis location, either within the upper half of the groove (five) or in the lower half of the groove or shaft (12). Patient outcomes were assessed with visual analog scale scores for pain, American Shoulder and Elbow Surgeons scores, and Constant-Murley scores. Minimum followup was 12 months (mean, 28 months; range, 12–69 months). Results Two patients had persistent pain at 12 months; both had a tenodesis in the upper half of the groove. The overall American Shoulder and Elbow Surgeons and Constant-Murley scores were improved at latest followup. Conclusions Arthroscopic suprapectoral biceps tenodesis represents a new technique for distal tenodesis. Our preliminary observations suggest a more distal tenodesis location may decrease the incidence of persistent postoperative pain at the bicipital groove, although additional research is needed to definitively state whether the proximal location is in fact more painful. Level of Evidence Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Purpose Several kinds of anterolateral ligament (ALL) reconstructions to augment intra-articular anterior cruciate ligament reconstruction to better control anterolateral rotational instability (ALRI) have been reported. However, the optimal femoral attachment site for ALL reconstruction is still unclear. The purpose of this study was to investigate the effects of different femoral attachment sites on the tension changes through knee motions in different situations in order to determine a recommended femoral attachment site for ALL reconstruction. Methods Six fresh-frozen cadaveric knees were included. ALL reconstructions were performed with three different femoral attachment sites (F1: 2 mm anterior and 2 mm distal to the lateral epicondyle, F2: 4 mm posterior and 8 mm proximal to the lateral epicondyle and F3: position for the lateral extra-articular tenodesis). The graft tension changes were measured by a graft tensioning system during knee flexion–extension and manual maximum internal/external tibial rotation in the following situations: (1) intact, (2) ALL cut, (3) ALL and ACL cut and (4) ALL cut and ACL reconstructed. Effects of the different femoral attachment sites, the route superficial or deep to the LCL, and the situations of (1) to (4) were calculated via repeated-measures analysis of variance. Results The tension of F1 was higher in flexion and lower in extension, whereas the tension of F2 and F3 was higher in extension and lower in flexion. F2 showed the smallest tension change. Situations of (1) to (4) did not affect tension changes. The graft tension became higher with internal rotation and lower with external rotation regardless of femoral attachment sites or situations. Conclusion With F2—4 mm posterior and 8 mm proximal to the lateral epicondyle—the reconstructed ALL had the least tension change with only a slight increase in tension as the knee extended. This result indicates that F2 is recommended for ALL reconstruction to better control ALRI, which will help determine the optimal femoral tunnel position for ALL reconstruction.

The study found that no significant differences were found in terms of subjective IKDC, ACL-RSI, pivot-shift grade, and subjective knee instability among the three ACLR techniques at short-term follow-up. More grafts were required during the operation, which may cause more complications at the donor site. [...]the complex surgical procedure and the large amount of ligament weaving may lead to an increased surgical time. [...]we respect and thank the authors for their research, which provides new ideas and directions for further improving the functional recovery of patients with ACL injury.