Between 1999 and 2001, we performed 181 arthroscopic rotator cuff repairs. In 22 of these repairs, we found severe associated biceps tendon lesions that were repaired with two new arthroscopic techniques of tenodesis incorporating the biceps tendon in the rotator cuff suture. In all patients appropriate nonoperative therapy, including nonsteroidal anti-inflammatory drugs, physiotherapy, rest and local injections, had previously failed. None of the patients had undergone a prior surgical procedure on the affected shoulder.
We performed all preoperative evaluations the day before surgery and postoperative evaluations at the final follow-up. The mean follow-up period was 47.2 months (range 36–59). Each patient was evaluated for arm dominance, trauma history, onset, duration and the type of preoperative symptoms, activity level, acromial morphology, type of lesion, pre- and postoperative ROM and pre- and postoperative modified shoulder score (UCLA). Pain onset was considered acute if the patient could remember a single event that initiated the pain. The activity level was evaluated and categorised as sedentary, light work and heavy manual work. The anterior acromion was classified according to the classification of Bigliani et al. [2
]. All patients had a full-thickness rotator cuff lesion with or without retraction.
Each patient had at least one positive biceps test (Speed’s test, Yergason’s test, active compression test or biceps instability test). All patient were examined by the senior author. All shoulders had preoperative assessment by the use of standard radiographs (anteroposterior projections, neutral, external and internal rotation, a lateral view of the scapula and an axillary view) and MRI scans.
A modified UCLA (University of California, Los Angeles) shoulder rating scale was used to evaluate preoperative and postoperative shoulder pain, function and range of motion, strength and patient satisfaction. The maximum score obtainable is 35. The scores were divided into excellent (34–35 points), good (28–33), fair (21–27) and poor (0–20).
Arthroscopic repair of the lesions was performed by one of two new tenodesis techniques, in all cases incorporating the biceps tendon in the rotator cuff suture. Patients were randomised into one of two groups:
- tenodesis without tenotomy
- tenodesis with tenotomy.
The assignment of patients to one of the two groups was based on computerised randomization. All surgical interventions were performed by the same surgeon.
Patient demographics are presented in Tables (tenodesis without tenotomy) and (tenodesis with tenotomy).
In group 1 (tenodesis without tenotomy), there were six men and five women. The mean age was 60.3 years (range, 41 to 79). The injury was reported to be acute in five of the patients and insidious in the other six. The dominant arm was affected in seven cases. Three patients were engaged in professions involving regular heavy manual activity (e.g., carpenter).
The biceps tendon was dislocated in four cases, unstable in three cases and torn by more than 50% of its diameter in four cases.
In group 2 (tenodesis with tenotomy), there were five men and six women. The mean age was 58.1 years (range, 40 to 81). The injury was reported to be acute in four of the patients and insidious in the other seven. The dominant arm was affected in eight cases. Three patients were engaged in professions involving regular heavy manual activity. The biceps tendon was dislocated in three cases, unstable in four cases and torn by more than 50% of its diameter in four cases. Statistical analyses were performed with the Wilcoxon Sign Rank test. Significance was set at P<0.05.
Patients underwent brachial plexus block, associated in five cases with a general anaesthesia, and were then placed in a lateral decubitus position. The arm was suspended at approximately a 45° angle of abduction and 10° forward flexion. Distraction of the shoulder joint was accomplished with 10 to 14 lb of traction. Four to six portals were used during the procedure. A posterior portal was created, and the arthroscope was inserted into the glenohumeral joint. A thorough diagnostic arthroscopic examination was then performed for evaluation of the extent of the rotator cuff tear, lesions of the biceps tendon and other associated lesions. The most important subacromial portals were the posterolateral viewing, the anterolateral and the lateral working portal, equipped with an 8.25-mm cannula. To control bleeding we used radiofrequency with adrenalin admixture to the irrigation fluid and asked the anaesthetist to lower the systolic blood pressure to 90 mmHg if possible. An arthroscopic pump maintained a fluid pressure of 40 mmHg that could be increased temporarily on demand.
A spinal needle was introduced percutaneously to ascertain the precise location for placement of the anterolateral portal created approximately 2 to 3 cm anterior and lateral to the anterolateral corner of the acromion. If the subscapularis tendon was involved, an anterior midlateral portal was created just superior to the lateral half of the subscapularis tendon. The arthroscope was used through the posterior portal to gain visualisation of the biceps tendon. The lateral portal was used to mobilise the rotator cuff back to its bony insertion.
Using a burr through the lateral portal, the articular and bony surface was abraded under the biceps tendon, just proximal to the bicipital groove. Shifting to the lateral portal as a viewing portal, the anterolateral portal was used to insert the first suture anchor slightly proximal to the bicipital groove (Fig. ).
Arthroscopic view from a lateral portal showing suture anchor proximal to the bicipital groove. (A, anchor; Bt, biceps tendon; Bg, bicipital groove)
A penetrator suture passer (Arthrex) was passed through the anterior leaf of the rotator cuff tear (Fig. a) and through the biceps tendon (Fig. b); the sutures were then retrieved through the posterior edge of the rotator cuff tear from a posterior portal in the same manner.
Fig. 2 Arthroscopic view through a lateral portal showing: (a) penetrator passage through the anterior leaf of the rotator cuff and the biceps. (b) The retrieving of the sutures from an anterolateral portal. (Bt, biceps tendon; ARC, anterior leaf of rotator (more ...)
Both ends were tied with a Sixth Finger knot pusher (Arthrex) providing a margin convergence of the two edges of the cuff (Figs. , ). One to two double-loaded anchors (Corkscrew Arthrex) in a double row format were used depending on the size of the rotator cuff footprint.
Arthroscopic view through a lateral portal showing the sutures passed through the biceps and the anterior leaf of the cuff. (Bt, biceps tendon; H, humeral head; S, Anchor suture)
Arthroscopic view through a lateral portal before tying knots. (ARC, rotator cuff; Bt, biceps tendon; S, Anchor suture; D, side to side suture
The remaining intra-articular tendon stump of the biceps was resected in 11 patients (group 2) and left attached at the glenoid tubercle in 11 patients (group 1). The surgery was concluded with an acromioplasty, removing anterior and lateral bone spurs in cases of type 2 and 3 acromion.
Postoperative management was the same for both groups. The arm was supported using a sling with an abduction pillow for 6 weeks. Active elbow flexion and extension were allowed, but terminal extension was restricted. Passive external rotation was started from the first day after surgery and maintained within a comfortable range. Overhead stretching was restricted until 6 weeks postoperatively to avoid damaging the repair. At 6 weeks the sling was removed, and overhead stretching with a rope and pulley were started. Isotonic strengthening and rehabilitation of the rotator cuff, deltoid and scapular stabilisers were initiated at 10 or 12 weeks after the operation. The rehabilitation was continued for 6 months. Heavy manual work and overhead activities were allowed after a good restoration of the shoulder strength, which occurred at 6 to 10 months after surgery.