Proximal Bicep Pathology: Leave it, Cut it, Fix it?

Transcription

1 Proximal Bicep Pathology: Leave it, Cut it, Fix it? Jason Clark, D.O. AOAO 2018 Fall Meeting Atlanta, Georgia

2 Disclosures No Disclosures

3 Pathogenesis LHBT is a primary pain generator in anterior shoulder. Sensory and sympathetic innervation Substance P and calcitonin gene-related peptides present Vascular anatomy role Hypovascular areas Increased mechanical strain

4 Physical Exam and Imaging Exam Anterior shoulder pain TTP over the bicipital groove Snap or Pop on ROM Popeye deformity Provocative Exam Speed Imaging Xrays Arthrography Ultrasound MRI Arthroscopy Ferguson Bicep Instability O brien

5 Proximal Bicep Pathology Isolated Tendinitis Rare (5%) Instability + Lesion of pulley system and RCT Instability + SLAP lesion

6 Proximal Bicep Pathology Isolated Tendinitis Rare (5%) Instability + Lesion of pulley system and RCT Instability + SLAP lesion

7 Isolated Bicep Tendinitis Treatment Nonoperative Rest NSAIDs Injections (subacromial/glenohumeral/bicipital sheath) PT

8 Isolated Bicep Tendinitis Operative Decompression Release of Transverse Humeral Ligament via scope vs open approach Tenotomy Advantages: technically easier, simpler rehab, no need for immobilization Disadvantages: Risk of Popeye deformity (70%), bicep cramping, and increased fatiguability (40%). Patient satisfaction: >90% Several studies state that >60 y/o did not appreciate fatigue

9 Isolated Bicep Tendinitis Operative Tenodesis Open/Scope Advantages: Better cosmesis, restoration of strength Disadvantages: More technically challenging, cost of implant, longer rehab, immobilization, possible failure of fixation

10 Bicep Tenodesis Goal: Preserve and Restore Length of LHBT Locations/Techniques vary Arthroscopic, Mini-open, Soft Tissue, Suprapectoral, Subpectoral, etc Keyhole, scope w screw/anchor, unicortical/ bicortical.

11 Isolated Bicep Tendinitis Tenodesis Younger patients Athletes Laborers Cosmetic concern Tenotomy Older individuals Non-laborers Cosmesis not an issue Unwilling to be compliant with rehab/post op instructions

12 Proximal Bicep Pathology Isolated Tendinitis Rare (5%) Tendon Instability + Lesion of pulley system and RCT Tendinitis/Instability + SLAP lesion

13 Proximal Biceps Complex Anterior Supraspinatus LHB Pulley CHL SGHL Superior Subscapularis

14 Habermeyer and Walch Classification

15 The Hidden Lesion Murthi et al (JSES 2000) 200 shoulders: SAD + RCR Incidence related to extent of the cuff disease 18% free of biceps disease 50% of biceps disease not seen during arthroscopy

16 Biceps Instability Associated with: Subscapularis tears (most common) Tears of coracohumeral and/or SGHL complex Medial subluxation/dislocation is most common

17 Biceps Instability Treatment: Nonoperative: NSAIDs, PT, Injection, Rest. Operative: Repair/Reconstruction of Pulley complex and/or Rotator Cuff (<50% Biceps involvement) Tenodesis Tenotomy

18 Results of Tenotomy w RCT Walch et al (JSES 2005) 307 bicep tenotomy with full thickness RCT 57 mo f/u Average age of 64 y/o 87% of patients were satisfied/very satisfied No fair/poor result due to cosmesis Showed tenotomy can produce a favorable outcome

19 Results of Tenotomy Gill et al (JSES 2001) Explored 30 pts with isolated scope tenotomy High rate of pain free recovery (97%), RTW (97%, 2 wk avg), RTS (90% at previous level) Mean ASES score of 81.8 Complication rate of 13.3% Kelly et al (AJSM 2005) 40 pts treated with scope tenotomy High patient satisfaction scores ASES avg 77.6 Popeye deformity 70% Fatigue discomfort (38%)

20 Results of Tenotomy Kempf et al (Arthroscopy 1999) 210 patients with scope managed RCT 18% Tenotomy Compared to nontenotomized group: Significant improvements in level of physical activity, active mobility, and pain variables

21 Proximal Bicep Pathology Isolated Tendinitis Rare (5%) Instability + Lesion of pulley system and RCT Tendinitis/Instability + SLAP lesion

22 Snyder Classification

23 SLAP tear Type 2 SLAP Most common Usually occur in setting of RCT or OA Treatment: Nonoperative: Rest, NSAIDs, PT (Reduce GIRD and scapular dyskinesia) Operative: Repair, Tenodesis, Tenotomy.

24 SLAP Repair Thought as the standard of care of unstable labral tear involving the LHBT Boileau et al (AJSM 2009) Kim et al (JBJS 2003) Maffet et al (AJSM 1995) Snyder et al (JSES 1995) Rhee et al (Arthroscopy 2005) O Brien et al (Arthroscopy 2002) Pagnani et al (Arthroscopy 1995) Trend towards poor results in patient with SLAP repair and concurrent SAD when they were y/o Recommended not repairing SLAP in over 40 y/o

25 Franceschi et al (AJSM 2008) Level 1 RCT Compared 31 patients with RCR with SLAP repair vs 32 patients with RCR with tenotomy All patients over 50 y/o with minimum 2.9 year f/u Found no advantages when comparing ROM values and UCLA scores Authors concluded tenotomy with RCR provided a better clinical outcome

26 Forsythe et al (JBJS 2010) Analyzed outcomes of SLAP + RCR (avg age 56.9) vs RCR (avg age 59.6) over 40 months Higher postoperative Constant score in concomitant repair group No significant difference in ROM Concluded that concomitant repair can be comparable to isolated RCR in middle aged adults.

27 Trends A 2016 survey of MLB physicians found 93% would repair a symptomatic SLAP Patterson et al (AJSM 2014) From : Bicep tenodesis has risen from 2 > 20% SLAP repair decreased 69.3% > 44.8% WHY???

28 Inconsistent Results with SLAP Repair Sayde et al (CORR 2012) 83% Good to excellent results Return to play 73%, but 63% of overhead athletes to previous level of play. Other studies report 22-85% return to preinjury level of sports activity. Frank et al (Adv Ortho 2013) < 20 y/o pts and overhead throwers were more likely to require revision surgery >40 y/o pts more likely to have lower post op ASES scores

29 Straus et al (JSES 2014) Evaluated experimental type II SLAP lesions Produced increased translation anteriorly, posteriorly and ABER. Bicep Tenodesis No change in translation compared to SLAP lesion presence. Recommended tenodesis as a viable alternative to SLAP repair in symptomatic SLAP tear Advised caution in overhead throwers due to increased translation.

30 Professional Baseball Players Fedoriw et al (AJSM 2014) Level IV Case series Retrospective review of 68 patients with MRI documented SLAP Pitchers: Nonoperative program (n=21) - RTP 40%, RPP 22% Operative (n=27) - RTP 48%, RPP 7% Position players: Nonoperative (n=10) - RTP 39%, RPP 26% Operative (n=13) - RTP 85%, RPP 54% Concluded non-surgical treatment has a reasonable success rate Return after surgery for pitchers was low.

31 Hurley et al (JSES 2018) Level III meta-analysis 5 studies with 234 patients Biceps tenodesis (mean age 45.4 y/o) vs labral repair (mean age 38.8 y/o) in SLAP tears BT Patient satisfaction 95.6% vs 76.2% BT return to sport rate 81.3% vs 64.3% No difference in complication rates or functional outcomes

32 The Studies Continue

33 Summary Trends: All depends on age and activity level, patient factors Nonoperative vs Repair <25 y/o Elite overhead athlete Bicep Tenodesis y/o Non elite overhead athlete Laborer Cosmesis Concern Bicep Tenotomy > 40 y/o Sedentary Not concerned about cosmesis

34 Sources Boileau P, Parratte S, Chuinard C, Roussanne Y, Shia D, Bicknell R: Arthroscopic treatment of isolated type II SLAP lesions: Bicep tenodesis as an alternative to reinsertion. Am J Sports Med 2009;37(5): Boileau P, Baque F, Valerio I, Ahrens P, Chuinard C, Trojani C: Isolated arthroscopic biceps tenotomy or tenodesis improves symptoms in patients with massive irreparable rotator cuff tears. J Bone Joint Surg Am 2007;89(4): Chalmers PN, Monson B, Frank RM, et al: Combined SLAP repair and biceps tenodesis for superior labral anterior posterior tears. Knee Surg Sports Traumatol Arthrsoc 2016;23(12) Fedoriw WW, RAmkumar P, McCulloch PC, Lintner DM: Return to play after treatment of superior labral tears in professional baseball players. Am J Sports Med 2014;42(5): Forsythe B, Guss D, Anthony SA, Martin SD. Concomitant arthroscopic SLAP and rotator cuff repair. J Bone Joint Surg Am 2010; 92(6): Franceschi F, Longo UG, Ruzzini L, Papalia R, Rizzello G, Denaro V: To detach the long head of the biceps tendon after tenodesis or not: Outcome analysis at the 4-year follow-up of two different techniques. Int Orthop 2007; 31(4): Franceschi F, Longo UG, Ruzzini L, Rizzello G, Matfulli N, Denaro V: No advantages in repairing a type II superior labrum anterior superior (SLAP) lesion when associated with rotator cuff repair in patients over 50: a randomized controlled trial. Am J Sports Med 2008; 36: Frank RM, Cotter EJ, Strauss EJ, Jazrawi LM, Romeo AA. Management of biceps tendon pathology: From the glenoid to the radial tuberosity. JAAOS 2018;26(4):e77-e89. Frank RM, Nho SJ, MGill KC, et al: Retrospective analysis of arthroscopic superior labrum anterior to posterior repair: Prognostic factors associated with failure. Adv Orthop 2013;2013: Gill TJ, McIrvin E, Mair SD, Hawkins RJ: Results of biceps tenotomy for treatment of pathology of the long head of the biceps brachii. J Shoulder Elbow Surg 2001; 10(3): Habermeyer P, Magosch P, Pritsch M, Scheibel MT, Lichtengerg S: Anterosuperior impingement of the shoulder as a result of pulley lesions: A prospective arthroscopic study. J Shoulder Elbow Surg 2004;13(1): Hurley ET, Fat DL, Duigenan CM, Miller JC, Mullett H, Moran CJ. Bicep tenodesis versus labral repair for superior labrum anterior-to-posterior tears: a systematic review and meta-analysis. J Shoulder Elbow Surg 2018;27:

35 Sources Maffet MW, Gartsman GM, Moseley B. Superior labrum-biceps tendon complex lesions of the shoulder. Am J Sports Med 1995;23: Morgan CD, Burkhart SS, Palmeri M, Gillespie M. Type II SLAP lesions: three subtypes and their relationships to superior instability and rotator cuff tears. Arthroscopy 1998;14: Murthi AM, Vosburgh CL, Neviaser TJ: The incidence of pathologic changes of the long head of the biceps tendon. J Shoulder Elbow Surg 2000; 9(5): Kelly AM, Drakos MC, Fealy S, Taylor SA, O Brien SJ: Arthroscopic release of the long head of the biceps tendon: Functional outcome and clinical results. Am J Sports Med 2005;33(2): Kempf JF, Gleise P, Bonnomet F, et al. A multicenter study of 210 rotator cuff tears treated by arthroscopic acromioplasty. Arthrscopy 1999; 15: Kim TK, Queale WS, Cosgarea AJ, McFarland EG. Clinical features of the different types of SLAP lesions: an analysis of one hundred and thirty-nine cases: superior labrum anterior posterior. J Bone Joint Surg Am. 2003;85: O Brien SJ, Allen AA, Coleman SH, Drakos MC. The trans-rotator cuff approach to SLAP lesions: technical aspects for repair and a clinical follow-up of 31 patients at a minimum of 2 years. Arthroscopy 2002;18: Pagnani MJ, Speer KP, Altchek DW, Warren RF, Dines DM. Arthroscopic fixation of superior labral lesions using a biodegradable implant: a preliminary report. Arthroscopy 1995;11: Patterson BM, Creighton RA, Spang JT, Roberson JR, Kamath GV: Surgical trends in the treatment of superior labrum anterior posterior lesions of the shoulder: Analysis of data from the American Board of Orthopaedic Surgery Certification Examination Database. Am J Sports Med 2014;42(8): Rhee YG, Lee DH, Lim CT. Unstable isolated SLAP lesion: clinical presentation and outcome of arthroscopic fixation. Arthroscopy 2005;21:1099. Sayde WM, Cohen SB, Ciccotti MG, Dodson CC: Return to play after Type II superior labral anterior-posterior lesion repair in athletes: A systematic review. Clin Ortho Relat Res 2012;470(6): Snyder SJ, Banas MP, Karzel RP. An analysis of 140 injuries to the superior glenoid labrum. J Shoudler Elbow Surg 1995;4: Strauss EJ, Salata MJ, Sershon RA, et al: Role of the superior labrum after biceps tenodesis in glenohumeral stability. J Shoulder Elbow Surg 2014;23(4): Walch G, Edwards TB, Boulahia A, Nove-Josserand L, Neyton L, Szabo I: Arthroscopic tenotomy of the long head of the biceps in treatment of rotator cuff tears: Clinical and radiographic results of 307 cases. J Shoulder Elbow Surg 2005; 14(3):

36 Thank you! Questions?